From the Guidelines
The most likely intervention to prevent loss of work time for this patient is physical therapy, as it is a nonpharmacologic therapy with proven benefits for acute low back pain, and can help maintain function while promoting recovery 1. This 54-year-old man presents with symptoms consistent with sciatica, likely due to a herniated disc or lumbar radiculopathy, as evidenced by his low back pain radiating below the knee and positive straight leg raise test.
Key Points to Consider
- Physical therapy is recommended as first-line treatment alongside the prescribed naproxen because it helps maintain function while promoting recovery.
- Studies show that remaining active rather than resting accelerates recovery from acute low back pain with radicular symptoms 1.
- Bed rest is actually counterproductive and can lead to deconditioning, while invasive options like discectomy would be premature without trying conservative management first.
- Opioid medications like hydrocodone carry risks of dependence and sedation that could impair work function.
- Physical therapy provides the patient with self-management strategies that can be continued at work, making it the most appropriate option to help this automobile mechanic maintain his occupational function while recovering.
Non-Pharmacological Interventions
Some key non-pharmacological interventions to consider include:
- Spinal manipulation, which is associated with small to moderate short-term benefits for acute low back pain 1.
- Intensive interdisciplinary rehabilitation, which is moderately effective for subacute low back pain 1.
- Exercise therapy, which can help reduce work disability for patients with subacute low back pain 1. However, the most recent and highest quality study suggests that physical therapy is the most likely intervention to prevent loss of work time for this patient 1.
From the Research
Interventions to Prevent Loss of Work Time
The patient's concern about his ability to perform his job as an automobile mechanic due to low back pain that radiates to just below his right knee is a significant issue. To address this, the following interventions can be considered:
- Beginning naproxen therapy, as already planned
- Additional interventions to prevent loss of work time, such as:
- Physical therapy: According to 2, work rehabilitation refers to the process of assisting workers to remain at work or return to work in a safe and productive manner. Physical therapy can play a crucial role in this process.
- Avoiding bed rest: There is no evidence to suggest that bed rest is beneficial for this patient, and it may even be counterproductive.
- Avoiding discectomy: Unless there are specific indications for surgery, discectomy is not likely to be necessary at this stage.
- Avoiding hydrocodone-acetaminophen therapy: According to 3, naproxen sodium was significantly more effective than hydrocodone plus acetaminophen in reducing pain intensity and providing greater pain relief over 12 hours.
- Avoiding prednisone therapy: There is no evidence to suggest that prednisone is necessary for this patient.
- Avoiding transcutaneous electrical nerve stimulation: According to 4, there is no significant difference in pain relief between transcutaneous electrical nerve stimulation and a non-steroidal anti-inflammatory drug for painful osteoarthritis.
Prevention of Work-Related Injuries
In addition to the above interventions, preventing work-related injuries is crucial to reducing lost workdays. According to 5, implementing a safe patient handling and mobility program can reduce work-related injuries by 86%. While this study is not directly related to the patient's occupation as an automobile mechanic, it highlights the importance of taking measures to prevent work-related injuries.
Naproxen Therapy
Naproxen has been shown to be effective in treating pain following different surgical interventions, eliminating or reducing the use of rescue opioids in many trials 6. It is also better tolerated than hydrocodone-acetaminophen therapy 3. Therefore, beginning naproxen therapy is a reasonable approach to managing the patient's pain.