Physiotherapy in Toronto for Lower Back

Acute lumbar disc prolapse can be very painful. Back pain that goes down the leg (called sciatica) often brings the patient in to the physician's office for help. Pain is managed with physiotherapy and medications such as antiinflammatories.

Another form of drug therapy is with muscle relaxers/relaxants. The most common drug family of muscle relaxants used are the benzodiazepines (e.g., Librium, Valium). These drugs are also used to treat anxiety because they have a sedative effect. But concerns about side effects of benzodiazepines has brought into question whether they should be used at all for acute low back pain associated with lumbar disc prolapse.

In general, benzodiazepines are safe and effective when used on a short term basis. Long-term use is really the sticking point. These medications can cause adverse psychological and physical effects. Patients can become addicted and become physically dependent on the drug. Withdrawal symptoms may occur when attempting to stop taking them.

In this study, the role of one specific benzodiazepine (diazepam, also known as valium) in the management of acute low back pain with sciatica is reviewed. All 60 patients enrolled in the study had been diagnosed as having a lumbar disc prolapse using imaging studies (CT scans and MRIs).

A disc prolapse is a type of disc herniation. The three main types of disc herniation can actually be divided into disc prolapse, disc herniation, and disc sequestration. In the case of a prolapse, the disc is bulging.

The inner portion of the disc (the nucleus) is intact has migrated or moved into the outer covering called the annulus. The direction of the disc material is usually backwards toward the spinal canal. A bulge or prolapsed disc can be large enough to actually press against the nearby spinal nerve root causing back and/or leg pain (sciatica).

The pain causes muscles to contract and hold that contracted position. The result is a protective muscle spasm that really only increases the pain. Muscle relaxants like diazepam are meant to break the pain-spasm cycle by relaxing the muscles in spasm. But do they really work? That's the question addressed here.

Patients in the study were divided randomly into two groups. Everyone received physiotherapyplus either diazepam (Valium) or a placebo (sugar pill). It was a double-blind study, which means none of the key players (patients, physicians, or physiotherapists) knew who was receiving a placebo versus the diazepam. Patients were allowed to take a pain reliever/antiinflammatory (Voltaren) as prescribed by their physician.

A specific type of physiotherapy approach was used with each patient. The concept is to find the direction of spinal movement that does not cause pain and does not reproduce the sciatica. The patient is then taught how to safely move in that direction repeatedly. The goal is to reduce the leg pain and centralize or move the pain to just the low back region (without leg pain).

Results were measured after seven days of treatment and again after six weeks and later one year after treatment. Per cent of total pain that was centralized (moved from down the leg to the low back) was the main measure. Other outcomes measured included intensity and duration of pain, muscle strength, ability to work, ability to walk, mobility (touching fingers to toes), and amount of pain medication used.

Surprisingly, the patients who received a placebo (sugar pill with no active ingredients) had the best pain relief and were in the hospital the shortest time. Return-to-work was faster in the placebo group. Patients taking the placebo were able to walk farther sooner than those patients taking the valium. Patients taking the valium were also more likely to ask for more medication and to take it over a longer period of time.

The authors concluded that benzodazepines should not be used for pain control in patients with sciatica from disc prolapse. In this study, pain was reduced much more effectively in the placebo group than in the group taking diazepam (Valium).

It has been suggested that muscle relaxants actually work against the goal of taking pressure off the spinal nerve. Muscle spasm and tightness can aid in putting pressure on the spine to maintain a position that will push the protruding disc back in place. The use of antiinflammatories, analgesics (pain relievers), and physiotherapy remain the most effective management plan for this problem.

Reference: Doris Brötz, et al. Is There a Role for Benzodiazepines in the Management of Lumbar Disc Prolapse with Acute Sciatica? In PAIN. June 2010. Vol. 149. No. 3. Pp. 470-475.

PhysioExcellence provides services for physiotherapy in Toronto.