EVIDENCE FOR PHARMACOLOGICAL MANAGEMENT OF ACUTE LOW BACK PAIN

David Tatham

PARACETAMOL

TYPE OF EVIDENCE / BENEFIT / NO BENEFIT
SYSTEMATIC REVIEW / No evidence. / No evidence
RCT / No evidence for paracetamol vs placebo. / No evidence

OPIATES

TYPE OF EVIDENCE / BENEFIT / NO BENEFIT / COMPARISON OF DIFFERENT OPIATES
SYSTEMATIC REVIEW / No evidence. / No evidence / No evidence
RCT / No evidence for opiates vs placebo. / No evidence / No evidence

NSAIDs

TYPE OF EVIDENCE / BENEFIT / NO BENEFIT / HARM / COMPARISON OF DIFFERENT NSAIDs
SYSTEMATIC REVIEW / NSAIDs significantly improved proportion of people experiencing global improvement at one week compared with placebo [1] / 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]
RCT / Diclofenac and ibuprofen improve global outcome at 7 days compared to placebo. [2] / No evidence / No significant difference between acemetacin and diclofenac in pain or global assessment. [4]
Improvement in functional status but no difference in pain at 10 days (COX-2 vs ibuprofen). [5]

MUSCLE RELAXANTS

TYPE OF EVIDENCE / BENEFIT / NO BENEFIT / HARM / COMPARISON OF DIFFERENT MUSCLE RELAXANTS
SYSTEMATIC REVIEW / Non-benzodiazepine muscle relaxants significantly reduce pain and improved global assessment after 2-4 days. [6] / Muscle relaxants (both benzodiazepines and non-benzodiazepines) significantly increased adverse effects, particularly central nervous system effects, compared with placebo. [6]
RCT / Diazepam reduced pain compared to placebo. [7]
Muscle relaxants reduced pain at 4 weeks compare to placebo. [8] / 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 / DIFFERENCE BETWEEN AGENTS / NO DIFFERENCE BETWEEN AGENTS
SYSTEMATIC REVIEW / No evidence. / No evidence.
RCT / 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.
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 / DIFFERENCE BETWEEN AGENTS / NO DIFFERENCE BETWEEN AGENTS
SYSTEMATIC REVIEW / No evidence / No evidence
RCT / 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 12.5mg tablets: a flexible dose, ibuprofen 200mg 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.