Efficacy of non-steroidal anti-inflammatory drugs for low back pain: a systematic review of randomised clinical trials

A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain: 6-month follow-up outcomes from the UCLA low back pain study

STUDY DESIGN

A randomized clinical trial.

OBJECTIVES

To compare the effectiveness of medical and chiropractic care for low back pain patients in managed care; to assess the effectiveness of physical therapy among medical patients; and to assess the effectiveness of physical modalities among chiropractic patients.

SUMMARY OF BACKGROUND DATA

Despite the burden that low back pain places on patients, providers, and society, the relative effectiveness of common treatment strategies offered in managed care is unknown.

METHODS

Low back pain patients presenting to a large managed care facility from October 30, 1995, through November 9, 1998, were randomly assigned in a balanced design to medical care with and without physical therapy and to chiropractic care with and without physical modalities. The primary outcome variables are average and most severe low back pain intensity in the past week, assessed with 0 to 10 numerical rating scales, and low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire.

RESULTS

Of 1,469 eligible patients, 681 were enrolled; 95.7% were followed through 6 months. The mean changes in low back pain intensity and disability of participants in the medical and chiropractic care-only groups were similar at each follow-up assessment (adjusted mean differences at 6 months for most severe pain, 0.27, 95% confidence interval, -0.32-0.86; average pain, 0.22, -0.25-0.69; and disability, 0.75, -0.29-1.79). Physical therapy yielded somewhat better 6-month disability outcomes than did medical care alone (1.26, 0.20-2.32).

CONCLUSIONS

After 6 months of follow-up, chiropractic care and medical care for low back pain were comparable in their effectiveness. Physical therapy may be marginally more effective than medical care alone for reducing disability in some patients, but the possible benefit is small.

Lumbosacral radiculopathies: conservative approaches to management

The prevalence of sciatica in Western society and its economic and functional impact make it an important problem to understand for treatment. Such understanding will impact greatly both medical management and decisions regarding activity, which could affect the perceived disability and financial dependence of a patient. This knowledge could be used to direct primary prevention, patient education, and future research efforts in back pain. The article also discusses that such strategies could improve health, decrease disability, and rein in costs.

Early intervention for acute back injury: can we finally develop an evidence-based approach?

OBJECTIVE

Several reviews of the treatment of acute low back pain have been published in the past and have formed the basis of clinical guidelines. However, these lack consistency in some areas and valid data in others. As the literature in this field has continued to expand, the present review was undertaken to establish whether the guidelines in current use are supported by more recently published, scientifically rigorous research, and whether additional consensus regarding treatment of acute low back injury has been forthcoming in recent years.

DESIGN

A review, and critical analysis, of literature relating to the treatment of acute low back pain that has been published since the production of the currently used clinical guidelines. The guidelines have been reviewed to assess whether their recommendations remain supportable.

CONCLUSIONS

Recent research appears to support current clinical guidelines, i.e. exercise may have a positive effect while bed rest is ineffective and may be harmful, simple analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) have short-term benefits, and spinal manipulation may be effective in the first four weeks; no evidence was found for traction or back schools. However, we need more randomized controlled trials of treatments shown to be successful with the chronic population, e.g. focused on understanding psychological determinants, and using a multidisciplinary biopsychosocial approach. In the future this may help us to prevent acute low back progressing to the chronic state.

Systemic drug treatment for chronic musculoskeletal pain

OBJECTIVE

The purpose of this review was to determine how effective different classes of analgesic agents are in the management of chronic pain.

METHODOLOGY

The literature search identified five systematic reviews and 18 randomized controlled trials to provide evidence about systemic drug treatment for chronic pain.

RESULTS

Studies in the systematic reviews were mainly of low back pain, and studies in the randomized controlled trials were mainly of fibromyalgia. Other studies investigated of rheumatic pain, musculoskeletal pain, chronic low back pain, and temporomandibular pain. Classes of analgesic agents reviewed were antidepressants, nonsteroidal anti-inflammatory drugs, muscle relaxants, opioid analgesics, and a number of miscellaneous agents.

CONCLUSIONS

For chronic pain, opioid analgesics provide benefit for up to 9 weeks (level 2). For chronic low back pain, the evidence shows that various types of nonsteroidal antiinflammatory drugs are equally effective or ineffective, and that antidepressants provide no benefit in the short to intermediate term (level 2). Muscle relaxants showed limited effectiveness (level 3) for chronic neck pain and for chronic low back pain for up to 4 weeks. For fibromyalgia, there is limited evidence (level 3) of the effectiveness of amitryptiline, ondansetron, zoldipem, or growth hormone, and evidence of no effectiveness for nonsteroidal anti-inflammatory drugs, malic acid with magnesium, calcitonin injections, or s-adenyl-L-methionine. For temporomandibular pain, oral sumatriptan is not effective (level 2). The remaining evidence was inadequate (level 4a) or contradictory (level 4b).

Safety, efficacy, and cost effectiveness of evidence-based guidelines for the management of acute low back pain in primary care

STUDY DESIGN

A case-control study involving parallel benchmarking audits was conducted.

OBJECTIVE

To compare the safety, efficacy, and cost effectiveness of evidence-based medical care and usual care for acute low back pain.

SUMMARY OF BACKGROUND DATA

Although several sets of guidelines have been promoted for the management of acute low back pain, there is no evidence that following guidelines results in better outcomes.

METHODS

Special clinics were established, at which trained medical practitioners managed patients with acute low back pain according to evidence-based guidelines. Their outcomes were audited by independent research nurses. Meanwhile, and separately, the outcomes of patients managed by their own general practitioners were audited by research nurses using the same instruments of assessment.

RESULTS

In both settings, patients showed remarkable degrees and rates of recovery, with low rates of recurrence. However, evidence-based medical care resulted in a significantly lower cost of treatment; a significantly greater reduction in pain, sustained at both 6 and 12 months; significantly fewer patients requiring continuing care at 3, 6, and 12 months; a significantly greater proportion of patients fully recovered at 12 months; and significantly greater proportions of patients rating their treatment as extremely helpful and offering positive, unsolicited comments about their treatment.

CONCLUSIONS

The immediate results from evidence-based care are marginally better than those from good usual care, but in the long term, evidence-based care achieves clinically and statistically significant gains, with fewer patients requiring continuing care and remaining in pain. Consumers approve of evidence-based care.

Effects of diclofenac and ketoprofen on nerve conduction velocity in experimental nerve root compression

STUDY DESIGN

The effects of diclofenac and ketoprofen on nerve conduction velocity in experimental nerve root compression were evaluated in a setup using an established pig model.

OBJECTIVE

To assess the effects of two potent nonsteroidal antiinflammatory drugs, diclofenac and ketoprofen, in experimental nerve root compression.

SUMMARY OF BACKGROUND DATA

Compression of spinal nerve roots is recognized to be of major etiologic importance for several common spinal pain syndromes. Secondary inflammatory changes, induced by microvascular permeability changes and leakage of inflammatory mediators into the endoneural tissue, have been proposed as important for the induction of spinal nerve root injury by chronic compression.

METHODS

This study involved 21 pigs. An ameroid constrictor was used to induce compression. Seven pigs were treated with daily intramuscular injections of diclofenac 3 mg/kg for 7 days. Seven other pigs were treated with daily intramuscular injections of ketoprofen 4 mg/kg. For a control, seven pigs did not receive any drug treatment. After 7 days, the pigs were reanesthetized, and the nerve conduction velocity in the compressed nerve root segments was determined.

RESULTS

The nerve conduction velocity was significantly higher (P < 0.05, Student's t test) in the pigs treated with diclofenac (50 +/- 16 m/second) than in the untreated pigs (32 +/- 15 m/second). The nerve conduction velocity also was significantly higher (P < 0.05) in the pigs treated with ketoprofen (59 +/- 16 m/second) than in the untreated pigs. There were no significant differences in nerve conduction velocity between pigs treated with ketoprofen and those treated with diclofenac.

CONCLUSIONS

The findings indicate that intramuscular administration of diclofenac or ketoprofen, both potent antiinflammatory drugs, may reduce nerve root dysfunction induced by compression of spinal nerve roots in an experimental pig model.

A critical review of reviews on the treatment of chronic low back pain

STUDY DESIGN

Systematic literature review.

OBJECTIVE

To critically appraise the methodology of systematic reviews of conservative therapies for chronic nonspecific low back pain and to study the relation between the methodologic quality and other characteristics of these reviews.

SUMMARY OF BACKGROUND DATA

Systematic reviews offer a concise summary of the evidence on treatment effectiveness, but flaws in their methodology can lead to invalid conclusions with serious implications for quality of patient care.

METHODS

Searches of MEDLINE, EMBASE, Psychinfo, and the Cochrane Library were conducted. Titles, abstracts, and articles were reviewed by two blinded authors using three inclusion criteria: 1) chronic nonspecific low back pain, 2) systematic review, and 3) conservative treatment intervention. Data were extracted from each review by three authors.

RESULTS

The search strategy retrieved 1102 titles and abstracts; 109 met inclusion criteria. A review of the full text of these articles excluded an additional 73 articles. Data abstraction and methodologic assessment were conducted on 36 articles reviewing 19 discrete interventions. The average quality score was 4.1, ranging from 1 (low) to 7 (high). There was a trend for recent reviews to be of higher quality. Fifty-six percent of the reviews had positive conclusions, but they had lower quality scores compared with those that had negative or uncertain conclusions. There were 27 (73%) qualitative and 10 (27%) quantitative summaries of results.

CONCLUSIONS

Although the overall quality of systematic reviews was satisfactory, the quality of the individual papers included in the reviews varied considerably. The reviews often provided contradictory evidence on the effectiveness of a wide range of commonly used conservative interventions for chronic nonspecific low back pain. These findings illustrate the pitfalls of systematic reviews where there are a number of low-quality trials and underscore the need for high-quality primary trials that will allow for more conclusive reviews.

Pharmacologic pain treatment of musculoskeletal disorders: current perspectives and future prospects

OBJECTIVE

The authors aimed to provide an educational update on the current evidence of the effectiveness of drug therapy in the treatment of musculoskeletal pain and to offer a perspective of possible future developments.

DESIGN

The authors used a pragmatic review of data provided by available systematic reviews and seminal controlled studies pertaining to the treatment of regional musculoskeletal pain problems.

RESULTS

Epidural steroids may offer limited, short-term benefit for sciatica. Local injections of steroids are either ineffective or provide short-lasting benefits. Nonsteroidal anti-inflammatory drugs and opioids reduce pain, but the effect size is modest. The literature does not support convincingly the use of antidepressants. Certain muscle relaxants may be useful in the treatment of back pain. Hyaluronic acid, neutraceutical agents, avocado-soybean unsaponifiable agents, oxaceprol and diacerein may be effective in the treatment of osteoarthritis, but the information regarding these new agents does not allow wholesale endorsement of these substances. Selective epidural injection of steroids at a target nerve root approached through the intervertebral foramin has the potential to replace the traditional epidural approach. Long-acting, C--fiber-specific local anesthetics are under investigation and could provide long-lasting pain relief without motor or sensory impairment. In the future, central hypersensitivity in chronic musculoskeletal pain might be treated using antagonists of the N-methyl-D-aspartate receptor. Cannabinoid agents produce antinociception and prevent experimentally induced hyperalgesia in animals, and they may find a role in pain management. Methods to optimize drug combinations are available.

CONCLUSIONS

The effectiveness of the currently available drugs in the treatment of musculoskeletal pain conditions is disappointing. Recent developments may open new perspectives in this area of pain medicine.

Evaluating and managing acute low back pain in the primary care setting

Acute low back pain is a common reason for patient calls or visits to a primary care clinician. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected. For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self-limited, many patients treat themselves without contacting their primary care clinician. When patients do call or schedule a visit, evaluation and management by primary care clinicians is appropriate. The history and physical examination usually provide clues to the rare but potentially serious causes of low back pain, as well as to identify patients at risk for prolonged recovery. Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation. For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations.

Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group

STUDY DESIGN

A systematic review of randomized and double-blind controlled trials was performed.

SUMMARY OF BACKGROUND DATA

Nonsteroidal anti-inflammatory drugs are the most frequently prescribed medications worldwide and are widely used for patients with low back pain.

OBJECTIVES

To assess the effects of nonsteroidal anti-inflammatory drugs in the treatment of nonspecific low back pain with or without radiation, and to assess which type of nonsteroidal anti-inflammatory drug is most effective.

METHODS

For this study, the Cochrane Controlled Trials Register, Medline and Embase, and reference lists of articles were searched. Two reviewers blinded with respect to authors, institution, and journal independently extracted data and assessed the methodologic quality of the studies. If data were considered clinically homogeneous, a meta-analysis was performed. If data were considered clinically heterogeneous, a qualitative analysis was performed using a rating system with four levels of evidence: strong, moderate, limited, and no evidence.

RESULTS

This review involved 51 trials and 6057 patients. Of these trials, 16 (31%) were of high quality. The pooled relative risk for global improvement after 1 week was 1.24 (95% confidence interval [CI] = 1.10-1.41), and for additional analgesic use was 1.29 (95% CI = 1.05-1.57), indicating a statistically significant but small effect in favor of nonsteroidal anti-inflammatory drugs as compared with a placebo. The results of the qualitative analysis showed that there is conflicting evidence (Level 3) that nonsteroidal anti-inflammatory drugs are more effective than paracetamol for acute low back pain, and that there is moderate evidence (Level 2) that nonsteroidal anti-inflammatory drugs are not more effective than other drugs for acute low back pain. There is strong evidence (Level 1) that various types of nonsteroidal anti-inflammatory drugs are equally effective for acute low back pain.

CONCLUSIONS

The evidence from the 51 trials included in this review suggests that nonsteroidal anti-inflammatory drugs are effective for short-term symptomatic relief in patients with acute low back pain. Furthermore, there does not seem to be a specific type of nonsteroidal anti-inflammatory drug that is clearly more effective than others. Sufficient evidence on chronic low back pain still is lacking.

Methodologic issues in low back pain research in primary care

STUDY DESIGN

Narrative review and discussion of the selected literature.

OBJECTIVES

To discuss some important methodologic challenges in low back pain research in primary care.

SUMMARY OF BACKGROUND DATA

Many methodologic problems must be confronted when conducting low back pain research. Some of these problems are back pain specific or specific to the primary care setting.

METHODS

Methodologic problems related to four research issues will be discussed: study designs, definition of low back pain, determinants of low back pain, and outcome assessment.

RESULTS

Two fundamentally different study designs are frequently used in low back pain research, namely observational studies and experimental studies. The definition of low back pain is typically restricted to a highly variables self-reported symptom, the sensation of pain in the back. There clearly is a need for an evidence-based classification system for low back pain. Because a tenable theoretical framework is lacking, it is difficult to know which determinants of low back pain should be quantified. Low back pain studies focus usually on health-related quality-of-life outcome parameters. The identification of the minimum clinically relevant changes for the most important outcome instruments needs further consideration.

CONCLUSIONS

In years to come, low back pain researchers are challenged to overcome some of these (and other) problems to enhance the quality of low back pain research in primary care.

Pharmacotherapy and osteoarthritis

Therapy for osteoarthritis (OA) is aimed at relieving symptoms and at maximizing function. Therapies can be considered as either symptom modifying OA drugs (SMOADs) or as disease modifying OA drugs (DMOADs). Currently available agents fall into the category of SMOADs. Analgesic medications, particularly paracetamol and capsaicin, have proven efficacy in OA and are recommended first line therapies. Non-steroidal anti-inflammatory drugs (NSAIDs) do appear to provide extra symptomatic benefit for some patients but have greater toxicity. Newer generation NSAIDs may have safety advantages which remain to be confirmed in practice. Further therapies are being developed which aim to prevent cartilage damage and/or aid cartilage restoration, but these DMOADs remain in the experimental stage.