EVIDENCE FOR PHARMACOLOGICAL MANAGEMENT OF ACUTE LOW BACK PAIN
David Tatham
PARACETAMOL
TYPE OF EVIDENCE
SYSTEMATIC REVIEW
RCT
BENEFIT
No evidence.
No evidence for paracetamol vs placebo.
NO BENEFIT
No evidence
No evidence
OPIATES
TYPE OF EVIDENCE
BENEFIT
NO BENEFIT
SYSTEMATIC REVIEW
RCT
No evidence.
No evidence for opiates vs placebo.
No evidence
No evidence
COMPARISON OF DIFFERENT
OPIATES
No evidence
No evidence
NSAIDs
TYPE OF EVIDENCE
BENEFIT
SYSTEMATIC REVIEW
NSAIDs significantly improved
proportion of people
experiencing global
improvement at one week
compared with placebo [1]
RCT
Diclofenac and ibuprofen
improve global outcome at 7
days compared to placebo. [2]
NO BENEFIT
HARM
COMPARISON OF
DIFFERENT NSAIDs
No evidence
One systematic review of harms
of NSAIDs found that ibuprofen
and diclofenac had the lowest
gastrointestinal complication
rate. [3]
No significant difference among
NSAIDs in outcome. [1]
No significant difference
between acemetacin and
diclofenac in pain or global
assessment. [4]
No evidence
Improvement in functional
status but no difference in pain
at 10 days (COX-2 vs
ibuprofen). [5]
MUSCLE RELAXANTS
TYPE OF EVIDENCE
SYSTEMATIC REVIEW
BENEFIT
NO BENEFIT
RCT
Muscle relaxants reduced pain at
4 weeks compare to placebo. [8]
COMPARISON OF
DIFFERENT MUSCLE
RELAXANTS
Muscle relaxants (both
benzodiazepines and nonbenzodiazepines) significantly
increased adverse effects,
particularly central nervous
system effects, compared with
placebo. [6]
Non-benzodiazepine muscle
relaxants significantly reduce
pain and improved global
assessment after 2-4 days. [6]
Diazepam reduced pain
compared to placebo. [7]
HARM
No significant difference in
disability between muscle
relaxants and placebo at 4
weeks. [8]
Carisoprodol significantly
increased overall improvement
compared with diazepam but
found no significant difference
in pain at 7 days. [9]
No significant difference
between diazepam and
tizanidine in pain or function at
7 days. [10]
COMPARISON OF VARIOUS PHARMACOLOGICAL AGENTS
ANALGESICS (PARACETAMOL OR OPIATES) vs NSAIDs
TYPE OF EVIDENCE
SYSTEMATIC REVIEW
DIFFERENCE BETWEEN AGENTS
No evidence.
NO DIFFERENCE BETWEEN AGENTS
No evidence.
No significant difference in symptoms at 10 weeks between
paracetamol and NSAIDs.
No difference between return to work times between paracetamol
and aspirin.
RCT
No evidence.
No difference in pain scores between paracetamol, aspirin and
indometacin groups.
No difference in pain scores or functional capacity between keorolac
and paracetamol/codeine groups [55]
NSAIDs vs MUSCLE RELAXANTS
TYPE OF EVIDENCE
SYSTEMATIC REVIEW
DIFFERENCE BETWEEN AGENTS
No evidence
RCT
No evidence
NO DIFFERENCE BETWEEN AGENTS
No evidence
3 RCTs show no significant difference in outcome between NSAIDs
alone and NSAIDs plus muscle relaxants.
REFERENCES
[1].
Van Tulder MW, Scholten RJPM, Koes BW, et al. Non-steroidal anti-inflammatory drugs (NSAIDs) for low back pain. In: The Cochrane Library, Issue 4, 2004.
Chichester, UK: John Wiley & Sons, Ltd.
[2].
Dreiser RL, Marty M, Ionescu E, et al. Relief of acute low back pain with diclofenac-K 12.5 mg tablets: a flexible dose, ibuprofen 200 mg and placebo-controlled
clinical trial. Int J Clin Pharmacol Ther 2003;41:375–385.
[3].
Henry D, Lim LLY, Rodriguez LAG, et al. Variability in risk of gastrointestinal complications with individual non-steroidal anti-inflammatory drugs: results of a
collaborative meta-analysis. BMJ 1996;312:1563–1566.
[4].
Laws D. Double blind parallel group investigation in general practice of the efficacy and tolerability of acemetacin, in comparison with diclofenac, in patients
suffering with acute low back pain. Br J Clin Res 1994;5:55–64.
[5].
Pohjolainen T, Jekunen A, Autio L, et al. Treatment of acute low back pain with the COX-2 selective anti-inflammatory drug nimesulide: results of a randomised,
double-blind comparative trial versus ibuprofen. Spine 2000;25:1579–1585.
[6].
van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low back pain. In: The Cochrane Library, Issue 4, 2004. Chichester, UK; John Wiley
& Sons Ltd.
[7].
Moll W. Therapy of acute lumbovertebral syndromes through optimal muscle relaxation using diazepam. Results of a double-blind study on 68 cases. Med Welt
1973;24:1747–1751.
[8].
Hoiriis KT, Pfleger B, McDuffie FC, et al. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. J
Manipulative Physiol Ther 2004;27:388–398.
[9].
Boyles W, Glassman J, Soyka J. Management of acute musculokeletal conditions: thoracolumbar strain or sprain. Double-blind evaluation comparing the efficacy
and safety of carisoprodol with diazepam. Today's Ther Trends 1983;1:1–16.
[10].
Hennies O. A new skeletal muscle relaxant (DS 103–282) compared to diazepam in the treatment of muscle spasm of local origin. Int Med Res 1981;9:62–68.
[11].
Innes GD, Croskerry P, Worthington J, Beveridge R, Jones D. Ketorolac versus acetaminophen-codeine in the emergency department treatment of acute low
back pain. J Emerg Med. 1998 Jul-Aug;16(4):549-56.