From the Research
The best approach to manage severe low back pain in a non-compliant patient with a weightlifting injury history involves a multi-modal strategy combining medication, physical therapy, and behavioral interventions, with a focus on non-pharmacologic treatments as the first line of management, as recommended by the most recent guidelines 1. The patient's history of non-compliance and weightlifting injury suggests the need for a comprehensive approach that addresses both the physical injury and compliance challenges.
- Initially, prescribe a short course of NSAIDs such as ibuprofen 600mg three times daily with food for 7-10 days, as they are the initial medication of choice for chronic low back pain 1.
- Physical therapy focusing on core strengthening and proper lifting techniques is essential, starting with 2-3 sessions weekly for 4-6 weeks, as it is a first-line treatment for chronic low back pain 2.
- To improve compliance, simplify the treatment regimen, provide clear written instructions, use reminder systems, and schedule frequent follow-ups every 2-3 weeks.
- Educate the patient about the injury mechanism and how improper weightlifting technique can exacerbate back problems.
- Consider cognitive behavioral therapy to address pain-related fear and avoidance behaviors. The use of muscle relaxants, antidepressants, and opioids should be avoided or used with caution, as the evidence for their effectiveness is limited and they may have significant side effects 3. It is also important to note that the patient's non-compliance with previous treatment recommendations, such as not following instructions not to lift weights, suggests the need for a more intensive approach to improve compliance and prevent further injury. The patient's current treatment plan, which includes increasing amitriptyline to 50 mg and prescribing T4s BID for 5 days, may not be the most effective approach, as the evidence for the use of these medications in chronic low back pain is limited 1, 4. A more comprehensive approach that addresses the patient's physical and behavioral needs, as outlined above, is likely to be more effective in managing the patient's severe low back pain and improving their quality of life.