What is the next treatment step for a 49-year-old female patient with obesity (Body Mass Index (BMI) of 36), chronic low back pain, and minimal response to physical therapy, with Magnetic Resonance Imaging (MRI) findings of multilevel disc desiccation, mild disc space narrowing, and multiple mild disc bulges, who prefers natural remedies over oral analgesia?

From the Guidelines

For this 49-year-old obese female with chronic low back pain and minimal response to physical therapy, I strongly recommend a multidisciplinary rehabilitation approach, as it has been shown to moderately reduce short-term and slightly reduce long-term pain intensity and disability compared with usual care 1. This approach should include a combination of non-pharmacological interventions, such as:

• Modified physical therapy program emphasizing core strengthening exercises, gentle yoga, and aquatic therapy to reduce pressure on the spine while improving mobility
• Acupuncture sessions (1-2 times weekly for 8-12 weeks) to stimulate endorphin release and modulate pain perception, as low-quality evidence showed that acupuncture was associated with moderate improvement in pain relief immediately after treatment and up to 12 weeks later compared with sham acupuncture 1
• Cognitive behavioral therapy (CBT) to address pain catastrophizing and develop coping strategies through 8-10 weekly sessions, as moderate-quality evidence showed that mindfulness-based stress reduction is an effective treatment for chronic low back pain 1
• Topical preparations containing capsaicin or arnica, and supplements like turmeric (1500mg daily with black pepper) or omega-3 fatty acids (2000-3000mg daily) for natural pain management
• A TENS unit used for 20-30 minutes several times daily to provide temporary relief by stimulating nerve fibers that block pain signals While not focusing solely on weight loss, incorporating anti-inflammatory dietary changes would benefit both pain management and overall health. This comprehensive approach addresses her preference for natural remedies while targeting the multifactorial nature of chronic back pain, potentially improving her quality of life and ability to exercise. Key considerations include:
• The patient's preference for natural remedies and avoidance of oral analgesia
• The need for a multidisciplinary approach to address the complex nature of chronic low back pain
• The importance of ongoing monitoring and adjustment of the treatment plan to ensure optimal outcomes.

From the FDA Drug Label

Active Ingredient Purpose Capsaicin 0.035% External Analgesic The FDA drug label does not answer the question.

From the Research

Treatment Options for Chronic Low Back Pain

The patient's condition, characterized by chronic low back pain, multilevel disc desiccation, mild to minimal disc space narrowing, and multiple mild disc bulges, requires a comprehensive treatment approach. Considering her preference for natural remedies and minimal response to physical therapy, the following options can be explored:

• Epidural Steroid Injections: This treatment has been shown to provide substantial relief for back pain and radicular nerve component 2, 3, 4. The procedure involves injecting steroids into the epidural space to reduce inflammation and alleviate pain. Studies have demonstrated the effectiveness of epidural steroid injections in managing lumbosacral radicular syndromes 3 and cervical radicular pain 4.
• Multidisciplinary Approach: A coordinated approach involving a team of specialists, including physicians, physical therapists, and psychologists, can be beneficial in managing complex pathologies associated with chronic health conditions 5. This approach can help address the patient's overall well-being and provide a comprehensive treatment plan.
• Epidural Injections with Lidocaine: Research suggests that epidural injections with lidocaine, with or without steroids, can be effective in managing spinal pain 6. A systematic review and meta-analysis found moderate evidence for the use of epidural injections with lidocaine, with or without steroids, in managing spinal pain secondary to multiple causes.

Considerations for Treatment

When considering treatment options, it is essential to take into account the patient's preferences, medical history, and current condition. The treatment plan should be tailored to address the patient's specific needs and provide the best possible outcome. Regular follow-up appointments and monitoring can help adjust the treatment plan as needed and ensure the patient receives optimal care.