RAMB Março/Abril 2016

oaquim

190

ssoc

ras

2016; 62(2):188-191

reatment

Patient advice

Advising the patient that the pain is benign and transient

is important because the intensity of pain can result in

great psychological impact on patients.

Recommendations are individualized, but bed rest

should be avoided, with return to normal activity as soon

as there is pain relief.

9,10

Efforts that require excessive

movement of the spine should be avoided such as mov-

ing up and down, prolonged postures, repetitive move-

ments and physical activity if there is pain.

Applying local heat can be helpful, but ice is not rec-

ommended.

Medication

Plain analgesic drugs such as acetaminophen and non-

steroidal anti-inflammatory drugs (NSAIDs) are effective

and recommended for pain control. There is evidence

that NSAIDs are first-line drugs for pain control.

Nonbenzodiazepine muscle relaxants can be pre-

scribed in the treatment of acute pain. These drugs should

be used with caution especially in the elderly because they

may cause dizziness and drowsiness, increasing the risk

of falls.

Diazepam and carisoprodol should also be used

with caution due to risk of addiction.

Opioids can be used in cases of severe pain, also with

caution, for the shortest time required, usually less than

two weeks.

The physician should always inform the patient of

the possible side effects of each drug class, as well as con-

sider probable drug interactions.

Controversial treatments

The use of orthotics, such as jackets, is not recommend-

ed as routine in the treatment of acute low back pain due

to a real difficulty to immobilize the spine and lack of sci-

entific studies that support their use.

Acupuncture, massage and spinal manipulation need

more evidence to be recommended as a treatment in the

acute phase of low back pain.

The use of oral or injectable corticosteroids is not rec-

ommended as routine in the treatment of acute low back

pain.

Recurrence

Although the recommendations for exercise and physi-

cal therapy in episodes of acute pain vary in the literature,

physical practice should be avoided at an early stage as it

usually causes exacerbation of pain. However, the promo-

tion of physical activities as soon as the patient’s symp-

toms have improved, with muscle strengthening and

stretching, improves the overall physical condition and

is recommended. Weight loss is also indicated.

Glotle et al. evaluated a series of 123 patients with

acute low back pain (less than 3 weeks duration) for the

first time.

Of these, 120 patients were reassessed after 3

months of follow-up. The authors found that between 1

and 3 months, 76% of patients had recovered. As poor

prognostic factors, they found that age over 45, smoking

habit, signs of neurological disorder and high levels of

stress at presentation were associated with non-recovery

of patients, characterizing the disease as multifactorial.

They suggested that a psychological approach should be

taken in conjunction with the treatment of pain in these

patients, since 24% were not fully recovered in 3 months.

Although the nature of pain is benign and self-limit-

ing in general, patients who do not recover in three months

tend to have chronic mild to moderate pain after a year.

Most patients experience symptom improvement after one

month, but the 1-year recurrence rate is high – about two

thirds of patients with an episode of acute low back pain

will have another in the following 12 months.

Improve-

ment is progressive and usually takes two to four weeks.

Encouraging changes in lifestyle, healthy habits and

physical activity, as well as dietary changes to prevent weight

gain and promote health, is essential to avoid relapses.

esumo

Abordagem inicial do paciente com lombalgia aguda

A dor lombar é uma das causas mais comuns de procura à

assistência médica em unidades de pronto atendimento. É

ainda a segunda causa de afastamento laboral. O reconheci-

mento de sinais de alerta de doenças graves, como tumores

e fraturas, por meio de anamnese e adequado exame clínico,

é fundamental para o adequado tratamento e a exclusão de

diagnósticos diferenciais. Na ausência de suspeita de doen-

ça grave subjacente, exames radiológicos subsidiários são des-

necessários. Ouso de analgésicos e anti-inflamatórios é o tra-

tamento de primeira escolha, podendo estar associado a

relaxantes musculares e opioides, comcautela emcasos mais

graves. Amaior parte dos pacientes apresentará melhora to-

tal dos sintomas após alguns meses; porém, umaminoria irá

desenvolver lombalgia crônica ou quadros recorrentes. O

adequado entendimento de todos esses pontos permite oti-

mizar resultados e evitar erros diagnósticos e terapêuticos.

Palavras-chave:

dor lombar, tratamento de emergência,

diagnóstico.