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Interventions Available Over the Counter and Advice for Acute Low Back Pain: Systematic Review and Meta-Analysis

      Abstract

      This systematic review evaluated evidence from randomized controlled trials investigating interventions available over the counter and advice that could be provided to people with acute low back pain. Searches were conducted on MEDLINE, Embase, Cochrane Database of Systematic Reviews, AMED, CENTRAL, and PsycINFO for eligible randomized controlled trials. The primary outcome measure was pain. Eligible controls included placebo, no treatment, or usual care. Two reviewers extracted data and rated study quality. A random effects model was used to pool trial effects with the overall strength of evidence described using the GRADE criteria. Thirteen randomized controlled trials (2,847 participants) evaluating advice, bed rest, simple analgesics (paracetamol, nonsteroidal anti-inflammatory drugs), heat application, and a topical rubefacient were included. There was low-quality evidence that bed rest is ineffective and very-low-quality evidence that advice is ineffective in the short, intermediate, and long terms. There was very-low-quality evidence that nonsteroidal anti-inflammatory drugs (ibuprofen and diclofenac “when required” dosing) provide an immediate analgesic effect (mean differences −10.9 [95% confidence interval = −17.6 to −4.2] and −11.3 [95% confidence interval = −17.8 to −4.9], respectively). There is very-low-quality evidence that heat wrap and a capsicum-based rubefacient provide an immediate analgesic effect (mean differences −13.5 [95% confidence interval = −21.3 to −5.7] and 17.5, P < .001, respectively), but there was no information on longer-term outcomes.

      Perspective

      There is limited evidence that nonsteroidal anti-inflammatory drugs, heat wrap, and rubefacients provide immediate pain relief for acute back pain and that bed rest and advice are both ineffective. Future research is needed to provide evidence to support rational use of over-the-counter remedies and advice for people with acute low back pain.

      Key words

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      References

        • Andersson G.B.
        Epidemiological features of chronic low-back pain.
        Lancet. 1999; 354: 581-585
        • Armijo-Olivo S.
        • Stiles C.R.
        • Hagen N.A.
        • Biondo P.D.
        • Cummings G.G.
        Assessment of study quality for systematic reviews: A comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public Health Practice Project Quality Assessment Tool: Methodological research.
        J Eval Clin Pract. 2012; 18: 12-18
        • Atkins D.
        • Best D.
        • Briss P.A.
        • Eccles M.
        • Falck-Ytter Y.
        • Flottorp S.
        • Guyatt G.H.
        • Harbour R.T.
        • Haugh M.C.
        • Henry D.
        • Hill S.
        • Jaeschke R.
        • Leng G.
        • Liberati A.
        • Magrini N.
        • Mason J.
        • Middleton P.
        • Mrukowicz J.
        • O'Connell D.
        • Oxman A.D.
        • Phillips B.
        • Schunemann H.J.
        • Edejer T.
        • Varonen H.
        • Vist G.E.
        • Williams Jr., J.W.
        • Zaza S.
        • GRADE Working Group
        Grading quality of evidence and strength of recommendations.
        BMJ. 2004; 328: 1490
        • Berenguera A.
        • Pujol-Ribera E.
        • Rodriguez-Blanco T.
        • Violan C.
        • Casajuana M.
        • de Kort N.
        • Trapero-Bertran M.
        Study protocol of cost-effectiveness and cost-utility of a biopsychosocial multidisciplinary intervention in the evolution of non-specific sub-acute low back pain in the working population: Cluster randomised trial.
        BMC Musculoskelet Disord. 2011; 12: 194
        • Bijur P.E.
        • Latimer C.T.
        • Gallagher E.J.
        Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department.
        Acad Emerg Med. 2003; 10: 390-392
        • Chou R.
        • Huffman L.H.
        Medications for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.
        Ann Intern Med. 2007; 147: 505-514
        • Chou R.
        • Huffman L.H.
        Nonpharmacologic therapies for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.
        Ann Intern Med. 2007; 147: 492-504
        • Coste J.
        • Le Parc J.M.
        • Berge E.
        • Delecoeuillerie G.
        • Paolaggi J.B.
        French validation of a disability rating scale for the evaluation of low back pain (EIFEL questionnaire).
        Rev Rhum Ed Fr. 1993; 60: 335-341
        • Dahm K.T.
        • Brurberg K.G.
        • Jamtvedt G.
        • Hagen K.B.
        Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica.
        Cochrane Database Syst Rev. 2010; : CD007612
        • De Morton N.A.
        The PEDro scale is a valid measure of the methodological quality of clinical trials: A demographic study.
        Aust J Physiother. 2009; 55: 129-133
        • Deyo R.A.
        • Weinstein J.N.
        Low back pain.
        N Engl J Med. 2001; 344: 363-370
        • Dreiser R.L.
        • Marty M.
        • Ionescu E.
        • Gold M.
        • Liu J.H.
        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
        • Dwamena F.
        • Holmes-Rovner M.
        • Gaulden C.M.
        • Jorgenson S.
        • Sadigh G.
        • Sikorskii A.
        • Lewin S.
        • Smith R.C.
        • Coffey J.
        • Olomu A.
        Interventions for providers to promote a patient-centred approach in clinical consultations.
        Cochrane Database Syst Rev. 2012; 12: CD003267
        • Dworkin R.H.
        • Turk D.C.
        • Wyrwich K.W.
        • Beaton D.
        • Cleeland C.S.
        • Farrar J.T.
        • Haythornthwaite J.A.
        • Jensen M.P.
        • Kerns R.D.
        • Ader D.N.
        • Brandenburg N.
        • Burke L.B.
        • Cella D.
        • Chandler J.
        • Cowan P.
        • Dimitrova R.
        • Dionne R.
        • Hertz S.
        • Jadad A.R.
        • Katz N.P.
        • Kehlet H.
        • Kramer L.D.
        • Manning D.C.
        • McCormick C.
        • McDermott M.P.
        • McQuay H.J.
        • Patel S.
        • Porter L.
        • Quessy S.
        • Rappaport B.A.
        • Rauschkolb C.
        • Revicki D.A.
        • Rothman M.
        • Schmader K.E.
        • Stacey B.R.
        • Stauffer J.W.
        • von Stein T.
        • White R.E.
        • Witter J.
        • Zavisic S.
        Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations.
        J Pain. 2008; 9: 105-121
        • Engers A.
        • Jellema P.
        • Wensing M.
        • van der Windt D.A.W.M.
        • Grol R.
        • van Tulder M.W.
        Individual patient education for low back pain.
        Cochrane Database Syst Rev. 2008; : CD004057
        • Farrar J.T.
        • Portenoy R.K.
        • Berlin J.A.
        • Kinman J.L.
        • Strom B.L.
        Defining the clinically important difference in pain outcome measures.
        Pain. 2000; 88: 287-294
      1. Garcia Rodriguez LA: Variability in risk of gastrointestinal complications with different nonsteroidal anti-inflammatory drugs. Am J Med 104:30S–34S; discussion 41S–42S, 1998

        • Gilbert J.R.
        • Taylor D.W.
        • Hildebrand A.
        • Evans C.
        Clinical trial of common treatments for low back pain in family practice.
        BMJ (Clin Res Ed). 1985; 291: 791-794
        • Ginsberg F.
        • Famaey J.P.
        A double-blind study of topical massage with Rado-Salil ointment in mechanical low-back pain.
        J Int Med Res. 1987; 15: 148-153
        • Giraudeau B.
        • Rozenberg S.
        • Valat J.P.
        Assessment of the clinically relevant change in pain for patients with sciatica [Letter].
        Ann Rheum Dis. 2004; 63: 1180-1181
        • Goubert L.
        • Crombez G.
        • De Bourdeaudhuij I.
        Low back pain, disability and back pain myths in a community sample: Prevalence and interrelationships.
        Eur J Pain. 2004; 8: 385-394
        • Hancock M.J.
        • Maher C.G.
        • Latimer J.
        • McLachlan A.J.
        • Cooper C.W.
        • Day R.O.
        • Spindler M.F.
        • McAuley J.H.
        Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: A randomised controlled trial.
        Lancet. 2007; 370: 1638-1643
        • Hart L.G.
        • Deyo R.A.
        • Cherkin D.C.
        Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey.
        Spine. 1995; 20: 11-19
        • Hartling L.
        • Ospina M.
        • Liang Y.
        • Dryden D.M.
        • Hooton N.
        • Krebs Seida J.
        • Klassen T.P.
        Risk of bias versus quality assessment of randomised controlled trials: Cross sectional study.
        BMJ. 2009; 339: b4012
      2. Higgins JPT, Green S: Cochrane Handbook for Systematic Reviews of Interventions, version 5.0.2. Cochrane Collaboration, 2009

        • Hjermstad M.J.
        • Fayers P.M.
        • Haugen D.F.
        • Caraceni A.
        • Hanks G.W.
        • Loge J.H.
        • Fainsinger R.
        • Aass N.
        • Kaasa S.
        • European Palliative Care Research Collaborative (EPCRC)
        Studies comparing Numerical Rating Scales, Verbal Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: A systematic literature review.
        J Pain Symptom Manage. 2011; 41: 1073-1093
        • Indahl A.
        • Velund L.
        • Reikeraas O.
        Good prognosis for low back pain when left untampered: A randomised clinical trial.
        Spine. 1995; 20: 473-477
        • Jellema P.
        • Van Der Windt D.A.W.M.
        • Van Der Horst H.E.
        • Twisk J.W.R.
        • Stalman W.A.B.
        • Bouter L.M.
        Should treatment of (sub)acute low back pain be aimed at psychosocial prognostic factors? Cluster randomised clinical trial in general practice.
        BMJ. 2005; 331: 84-87
        • Laska E.M.
        • Sunshine A.
        • Marrero I.
        • Olson N.
        • Siegel C.
        • McCormick N.
        The correlation between blood levels of ibuprofen and clinical analgesic response.
        Clin Pharmacol Ther. 1986; 40: 1-7
        • Lewin S.A.
        • Skea Z.C.
        • Entwistle V.
        • Zwarenstein M.
        • Dick J.
        Interventions for providers to promote a patient-centred approach in clinical consultations.
        Cochrane Database Syst Rev. 2001; : CD003267
        • Lim S.
        • Vos T.
        • Flaxman A.
        • Danaei G.
        • Shibuya K.
        • Adair-Rohani H.
        • the Global Burden of Disease Study Group
        A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010.
        Lancet. 2012; 300: 2224-2260
        • Macedo L.G.
        • Elkins M.R.
        • Maher C.G.
        • Moseley A.M.
        • Herbert R.D.
        • Sherrington C.
        There was evidence of convergent and construct validity of Physiotherapy Evidence Database quality scale for physiotherapy trials.
        J Clin Epidemiol. 2010; 63: 920-925
        • Machado L.A.C.
        • Kamper S.J.
        • Herbert R.D.
        • Maher C.G.
        • McAuley J.H.
        Analgesic effects of treatments for non-specific low back pain: A meta-analysis of placebo-controlled randomized trials.
        Rheumatology (Oxford). 2009; 48: 520-527
        • Maher C.G.
        • Sherrington C.
        • Herbert R.D.
        • Moseley A.M.
        • Elkins M.
        Reliability of the PEDro scale for rating quality of randomized controlled trials.
        Phys Ther. 2003; 83: 713-721
        • Malmivaara A.
        • Hakkinen U.
        • Aro T.
        • Heinrichs M.L.
        • Koskenniemi L.
        • Kuosma E.
        • Lappi S.
        • Paloheimo R.
        • Servo C.
        • Vaaranen V.
        • Hernberg S.
        The treatment of acute low back pain-bed rest, exercises, or ordinary activity?.
        N Engl J Med. 1995; 332: 351-355
        • Milgrom C.
        • Finestone A.
        • Lev B.
        • Wiener M.
        • Floman Y.
        Overexertional lumbar and thoracic back pain among recruits: A prospective study of risk factors and treatment regimens.
        J Spinal Disord. 1993; 6: 187-193
        • Munir M.A.
        • Enany N.
        • Zhang J.-M.
        Nonopioid analgesics.
        Anesthesiol Clin. 2007; 25: 761-774
        • Nadler S.F.
        • Steiner D.J.
        • Erasala G.N.
        • Hengehold D.A.
        • Abeln S.B.
        • Weingand K.W.
        Continuous low-level heatwrap therapy for treating acute nonspecific low back pain.
        Arch Phys Med Rehabil. 2003; 84: 329-334
        • Nadler S.F.
        • Steiner D.J.
        • Petty S.R.
        • Erasala G.N.
        • Hengehold D.A.
        • Weingand K.W.
        Overnight use of continuous low-level heatwrap therapy for relief of low back pain.
        Arch Phys Med Rehabil. 2003; 84: 335-342
      3. NHMRC: Evidence-based management of acute musculoskeletal pain: A guide for clinicians. In: NHMRC, editor. Canberra, 2004

        • Ostelo R.W.
        • Deyo R.A.
        • Stratford P.
        • Waddell G.
        • Croft P.
        • Von Korff M.
        • Bouter L.M.
        • de Vet H.C.
        Interpreting change scores for pain and functional status in low back pain: Towards international consensus regarding minimal important change.
        Spine (Phila Pa 1976). 2008; 33: 90-94
      4. PEDro: Physiotherapy evidence database. How are trials rated? Available at: http://www.pedro.org.au/english/faq/#question_five. Accessed July 2013

        • Pengel L.H.
        • Refshauge K.M.
        • Maher C.G.
        • Nicholas M.K.
        • Herbert R.D.
        • McNair P.
        Physiotherapist-directed exercise, advice, or both for subacute low back pain: A randomized trial.
        Ann Intern Med. 2007; 146: 787-796
        • Pincus T.
        • Burton A.K.
        • Vogel S.
        • Field A.P.
        A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain.
        Spine. 2002; 27: E109-E120
        • Pinto R.Z.
        • Maher C.G.
        • Ferreira M.L.
        • Ferreira P.H.
        • Hancock M.
        • Oliveira V.C.
        • McLachlan A.J.
        • Koes B.
        Drugs for relief of pain in patients with sciatica: Systematic review and meta-analysis.
        BMJ. 2012; 344: e497
        • Pinto R.Z.
        • Maher C.G.
        • Ferreira M.L.
        • Hancock M.
        • Oliveira V.C.
        • McLachlan A.J.
        • Koes B.
        • Ferreira P.H.
        Epidural corticosteroid injections in the management of sciatica: A systematic review and meta-analysis.
        Ann Intern Med. 2012; 157: 865-877
      5. Report of the Consumer Health Care Products Association's Clinical/Medical Committee: White paper on the benefits of OTC medicines in the United States. Pharmacy Today October 2010, pp 68-79

        • Roland M.
        • Fairbank J.
        The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire.
        Spine (Phila Pa 1976). 2000; 25: 3115-3124
        • Rozenberg S.
        • Delval C.
        • Rezvani Y.
        • Olivieri-Apicella N.
        • Kuntz J.-L.
        • Legrand E.
        • Valat J.P.
        • Blotman F.
        • Meadeb J.
        • Rolland D.
        • Hary S.
        • Duplan B.
        • Feldmann J.L.
        • Bourgeois P.
        Bed rest or normal activity for patients with acute low back pain: A randomized controlled trial.
        Spine. 2002; 27: 1487-1493
        • Sostres C.
        • Gargallo C.J.
        • Arroyo M.T.
        • Lanas A.
        Adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs, aspirin and coxibs) on upper gastrointestinal tract.
        Baillieres Best Pract Res Clin Gastroenterol. 2010; 24: 121-132
        • Storheim K.
        • Brox J.I.
        • Holm I.
        • Koller A.K.
        • Bo K.
        Intensive group training versus cognitive intervention in sub-acute low back pain: Short-term results of a single-blind randomized controlled trial.
        J Rehabil Med. 2003; 35: 132-140
      6. Symptomatic treatment for acute low back pain. NPS MedicineWise. Available at: http://www.nps.org.au/conditions-and-topics/conditions/nervous-system-problems/pain/for-individuals/pain-conditions/low-back-pain/back-pain-acute-low/symptomatic-management-pad. Accessed February 2013

        • Van Tulder M.
        • Becker A.
        • Bekkering T.
        • Breen A.
        • Del Real M.T.G.
        • Hutchinson A.
        • Koes B.
        • Laerum E.
        • Malmivaara A.
        Chapter 3: European guidelines for the management of acute nonspecific low back pain in primary care.
        Eur Spine J. 2006; 15: S169-S191
        • Waddell G.
        1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain.
        Spine. 1987; 12: 632-644
        • Walker B.F.
        The prevalence of low back pain: A systematic review of the literature from 1966 to 1998.
        J Spinal Disord. 2000; 13: 205-217
        • Walker B.F.
        • Muller R.
        • Grant W.D.
        Low back pain in Australian adults: The economic burden.
        Asia-Pacific J Public Health. 2003; 15: 79-87
        • Wilk V.
        • Palmer H.D.
        • Stosic R.G.
        • McLachlan A.J.
        Evidence and practice in the self-management of low back pain: Findings from an Australian internet-based survey.
        Clin J Pain. 2010; 26: 533-540
        • Wilkinson M.J.
        Does 48 hours' bed rest influence the outcome of acute low back pain?.
        Br J Gen Pract. 1995; 45: 481-484