This article should interest all of you. The case is real and I am the patient. I experienced an unusual cause of low back pain, which involved both exercise and the use of aspirin. Although the conventional wisdom in medicine promulgates the use of NSAIDs, such as aspirin, as a valid and safe treatment for low back pain, I propose aspirin and exercise may cause low back pain that does not resolve – even with chiropractic interventions. I trust you will provide me with a great deal of feedback.
Subjective Findings
A 72-year-old chiropractic specialist, one who is also an associate professor of clinical sciences at the University of Bridgeport, School of Chiropractic Medicine, presents with acute, severe lower back and groin pain on the left side only. The pain has been progressively worsening and has now elevated to 8/10. He denies any trauma, lower extremity radiations, paresthesias, or weakness.
The pain is worse while sitting in an easy chair and attempting to rise; or with sleeping and attempting to roll over or get out of bed. He normally stretches his iliopsoas muscles for relief prior to his daily, early-morning, six-mile walk.
His past history reveals that he experienced chronic low back pain as a teenager following a motor-vehicle incident. After four years of suffering with lower back pain, he saw a chiropractic physician and gained relief with the first treatment. The chiropractic physician gave a diagnosis of chronic, posttraumatic lumbar facet syndrome. He successfully managed the condition with spinal manipulation.
The outcomes were excellent, with complete relief of the lower back pain. Consequently, the patient could return to athletic activities including Olympic-style weightlifting, baseball, basketball and football.
The patient experienced a "widowmaker" cardiac event eight years ago, which required a stent implant into the left anterior descending coronary artery. The surgery was a complete success. Unfortunately, the medical prescriptions including statins caused adverse reactions. The resultant statin myopathy caused severe muscle pain, a piriformis syndrome, brain fog, and muscle strains.
The patient advised his cardiologist that he would rather die than continue with the medications and the severe pain. A significant reduction in the dosage of statins over a two-year period reduced the muscle pain. Following the two years, he discontinued all of the prescribed medications except for 81 mg of baby aspirin per day.
Objective Findings
The patient is a mesomorph, standing with a slight anterior list of the lumbar spine. He is alert, a good historian, cooperative and demonstrating painful behaviors.
Orthotics are observed in the patient's New Balance walking shoes, which are fairly new without unusual wearing of the soles.
Palpation of the left lumbosacral facet produced significant sharp pain over the area of the capsule. Palpation of the left iliopsoas, quadratus lumborum and lumbosacral multifidi demonstrated hypertonicity and pain. The contralateral muscles were asymptomatic.
Kemp's procedure to the right produced pain at the left lumbosacral facets. Active lumbar range-of-motion testing demonstrated full ranges of motion with pain at the left lumbosacral facet. All other orthopedic and neurological testing findings were insignificant or within normal limits.
Assessment and Treatment Plan
Lumbar facet syndrome and myofascial pain. Possibly a repetitive strain due to the daily walking.
One soft-tissue treatment and spinal manipulation does reduce the sharp and localized, lumbar facet pain on the left; but not the deep, aching pain in the back, groin and abdomen. A second visit with lumbar manipulation also provides some relief of the sharp, localized back pain; but not the deep ache in the lower back, groin and abdomen.
Follow-Up and More Clues
Three weeks following the initial two visits, the patient returns for a follow-up. He advises that his lower back pain returned within three days of the second treatment, but now, all of his pain is gone.
When asked to recount his recent history, the patient explains that he scraped his right hand while cooking two weeks ago. He washed the wound and applied a Band Aid to stop the bleeding. The next morning, he was in severe lower back pain and had difficulty rising from bed. His wife then noticed that the sheets were covered in blood from his hand.
The patient advises that he discontinued the aspirin because of the blood-thinner effects. Within three days of stopping the aspirin, all of the pain in the back, groin and abdomen resolved. He could now return to his daily walk, sleep in bed or sit in his recliner without any pain. The patient is convinced that the aspirin and the walking were the causes of the pain in his lower back, groin and abdomen.
What Is Your Clinical Opinion?
Do you think aspirin and walking could be the cause of the patient's pain? Here's a three-question multiple-choice quiz:
1. What is the cause of the patient's pain?
a. Repetitive strain
b. Aspirin
c. Subluxation
d. A and B
e. None of the above
2. What would you do for the patient?
a. Advise him to discontinue taking aspirin
b. Advise him to discontinue walking
c. Advise him to discontinue sitting in a recliner
d. Schedule him for 12 weeks of chiropractic treatment
e. None of the above
3. What does the evidence offer?
a. I have no idea
b. No way does aspirin cause low-back pain
c. Aspirin relieves pain
d. Aspirin may cause musculoskeletal back and side pain
e. Aspirin may cause rhabdomyolysis
Clinical Pearls
As the patient (me) described above, I can tell you I had no idea exercise and aspirin might cause musculoskeletal pain in the back and side, but I do know now that it is possible to suffer an adverse reaction to aspirin that might cause low-back and side pain. I offer the following information for your consideration:
Here is one way to determine if a drug is causing muscle pain / myopathy: Overall, several criteria for reporting drug-induced myopathy can be recommended: lack of pre-existent muscular symptoms, a free period between the beginning of the treatment and the appearance of symptoms, lack of another cause accounting for the myopathy, and complete or incomplete resolution after withdrawal of the treatment. Rechallenge of the treatment is not advisable because of the risk of a serious relapse.1
Quiz Answers:
- D
- A
- D and E
Reference
- Le Quintrec J-S, Le Quintrec J-L. Drug-induced myopathies. Baillieres Clin Rheumatol, 1991 Apr;5(1):21-38.
