From the Guidelines
For intractable lower back pain exacerbated by coughing, a non-pharmacologic approach with spinal manipulation is recommended as the first line of treatment, given its association with small to moderate short-term benefits 1. When considering treatment options, it's essential to prioritize approaches that minimize risks and maximize benefits, especially for patients with chronic or subacute low back pain.
- The use of systemic corticosteroids is not recommended due to lack of evidence showing they are more effective than placebo 1.
- Medications like apsicum may be considered for acute exacerbations, but their benefits are small to moderate, and long-term use should be reserved for patients showing continued benefits without major adverse events 1.
- Non-pharmacologic therapies such as intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, yoga, cognitive-behavioral therapy, or progressive relaxation may be considered for patients with chronic or subacute low back pain, as they have proven benefits 1.
- For acute low back pain, supervised exercise therapy and home exercise regimens are not effective, and the optimal time to start exercise therapy after the onset of symptoms is unclear 1. Given the potential for disc involvement or facet joint irritation, especially with coughing exacerbating the pain, it's crucial to adopt a multimodal approach that includes:
- Gentle stretching exercises
- Physical therapy focusing on core strengthening
- Proper body mechanics
- Heat therapy for 15-20 minutes several times daily to relax muscles
- Cold therapy for acute inflammation
- Splinting the back by placing a pillow against it or hugging a pillow to the chest when coughing to minimize movement. If pain persists despite these measures, consulting a healthcare provider for further evaluation, which may include imaging studies and possibly interventional procedures like epidural steroid injections, is necessary.
From the Research
Treatment Options for Intractable Lower Back Pain
The treatment for intractable lower back pain exacerbation by coughing can be managed through various methods, including:
- Epidural steroid injections (ESI) which have been used for over 50 years to treat low back pain and radicular pain 2
- Caudal epidural injections with steroids or Sarapin, which have been shown to be effective in managing chronic, persistent low back pain that fails to respond to conservative modalities of treatment 3
- Repeat injections, which can provide greater clinical benefit in patients with partial pain reduction than intermittent injections performed only upon pain aggravation 4
Non-Pharmacologic Treatments
Non-pharmacologic treatments, such as:
- Physical therapy
- Chiropractic care
- Massage therapy
- Acupuncture are often recommended for chronic low back pain, but not typically for acute symptoms 5
Guideline Recommendations
The North American Spine Society's Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain provides evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain, but does not specifically address the treatment of intractable lower back pain exacerbation by coughing 6
Key Findings
Key findings from the studies include:
- Repeat TFESI conducted at 2- to 3-week intervals after the first injection in partial responders contributed to greater clinical benefit compared to intermittent TFESI performed only upon pain aggravation 4
- Caudal epidural injections with steroids or Sarapin are an effective modality of treatment in managing chronic, persistent low back pain that fails to respond to conservative modalities of treatment 3
- Non-pharmacologic treatments are not typically recommended for patients with acute symptoms, but are often recommended for chronic low back pain 5