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NSAIDs in chronic back pain

Three Part Question

[In patients with chronic 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 his general practitioner department with a history of long term back pain. he is normally fit and well, but developed lower back pain 3 months previously following a skiing holiday. 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 give advice on lifting. 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: [ or exp Anti-Inflammatory Agents, Non-Steroidal/ or or exp IBUPROFEN/ or or exp Diclofenac/ or] and [back or exp Back Pain/ or exp Low Back Pain/ or lumbar] 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 Studies of COX-2 NSAIDS were excluded as these have been widely withdrawn from clinical practice.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
51 randomised trials assessing the efficacy of non-steroidal anti-inflammatory drugs in the treatment of low back pain. Patients aged 18-65 included. Only patients with simple low back +/- sciatica included.Systematic review and meta-analysisNumber of trials found241 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 quality16 trials were considered high quality.
Number of trials on chronic back painOnly 4 trials were conducted in chronic back pain patients. All were comparisons of different medications so no pooled analysis was undertaken. The authors concluded that there is limited (level 3) evidence that NSAIDs are effective in the treatment of chronic low back pain.


Chronic back pain remains a significant cause of morbidity in western societies. For many patients a definitive cause is not found and they are treated with conservative management. For the majority of patients, conservative management will include pharmacological therapy. NSAIDs have been widely used for all forms of musculoskeletal pain and have been shown to be efficacious in acute back pain. This systematic review found 4 trials dealing with chronic back pain, but was unable to draw conclusions owing to the diverse research designs and findings.

Clinical Bottom Line

There is limited evidence for the efficacy of NSAIDS in the management of chronic low back pain.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.


  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