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Three Part Question

[In patients with acute low back pain] are [NSAIDs better than placebo or paracetamol] at [decreasing pain, improving mobility and speeding a return to normal function]

Clinical Scenario

A 35 year old man presents to the emergency department with acute low back pain. he is normally fit and well, but developed lower back pain the previous day after lifting a heavy box. There are no red flag symptoms and he has a normal neurological examination. You advise that he tries to mobilise as best he can and tell him that the prognosis is favourable. You offer analgesics but he appears to be concerned that you suggest that he takes paracetamol AND ibuprofen. He asks how much additional benefit
is he likely to get from the Ibuprofen as he is not keen on taking tablets.

Search Strategy

The Cochrane Library 2005, Issue 2 via NeLH
MEDLINE 1966- May 2005 using OVID interface via Athens
Cochrane {NSAID and back and pain}
Medline: [NSAID.mp. or exp Anti-Inflammatory Agents, Non-Steroidal/ or ibuprofen.mp. or exp IBUPROFEN/ or voltarol.mp. or exp Diclofenac/ or ketoralac.mp.] and [back pain.mp. or exp Back Pain/ or exp Low Back Pain/ or lumbar pain.mp.] limit 14 to reviews (sensitivity - online MEDLINE filter)

Search Outcome

Cochrane: 29 citations of which one was directly relevant to the 3 part question.
Medline: 228 papers of which the most recent well conducted systematic review was by the same authors as the cochrane review. Studies of COX-2 NSAIDS were excluded as these have been widely withdrawn from clinical practice. With this exclusion no new independant papers were found.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
van Tulder MW 2003	51 randomised trials assessing the efficacy of non-steroidal anti-inflammatory drugs in the treatment of acute low back pain. Patients aged 18-65 included. Only patients with simple low back +/- sciatica included.	Systematic review.	Number of trials found	241 trials screened of which 51 met inclusion criteria. 6057 patients represented.	Missing information not sought from primary authors. Wide variation in what the NSAIDS were compared against. Despite the large number of trials statistical pooling was not possible for most trials and their results.
			Trial quality	16 trials were considered high quality.
			NSAID vs Placebo	11 studies of which 9 addressed acute low back pain. Pooling of data done in 3-8 trials showed no difference in pain but benefits to global improvement and analgesic use. Qualititive analysis of all trials suggests benefit to NSAIDS. Meta-analysis Pain (3 trials) -0.53 [-2.74, 1.69]. Global improvement (6 trials) 1.24 [1.10, 1.41]. Side effects (8 trials) 0.83 [0.64, 1.08]. Analgesic use (3 trials) 1.29 [1.05, 1.57].
			NSAID vs Paracetamol	9 studies (5 high quality).There is conflicting evidence that NSAIDs are more effective than paracetamol for acute low back pain.
			NSAID vs other drugs	Six studies reported on acute low back pain, of which five, including the high quality study, did not find any differences between NSAIDs and narcotic analgesics or muscle relaxants.
			NSAID vs NSAID	studies compared different types of NSAIDs, it is not possible to make any statement on the relative effectiveness of these various types, because there are no studies that compared the same two NSAIDs for acute low back pain.

Comment(s)

Acute back pain is a common presentation to acute health services. Many patients are distressed and in pain and are usually grateful for any relief that might be offered. Although the data presented here does suggest that there is a small benefit to treating patients with NSAIDS the differences are perhaps dissapointing. Only a small number of trials could be statistically pooled and the reviews conclusions are therefore largely based around a qualititive interpretation of the high quality studies. To some degree the available evidence does not strictly answer the three part question as we are interested in the additional benefit of NSAIDs on top of paracetamol and no trials asked this question. We must therefore infer these results on a pathophysiological argument that as the analgesics work in different ways then it seems sensible to prescribe NSAIDs as well as paracetamol

Clinical Bottom Line

NSAIDs are effective in the treatment of acute low back pain.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. MW van Tulder, RJPM Scholten, BW Koes, RA Deyo Non-steroidal anti-inflammatory drugs for low-back pain The Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD000396. DOI: 10.1002/14651858