01.Relief from back pain?
Paracetamol is no better than a placebo at speeding recovery from acute episodes of lower back pain according to a large randomised trial carried out in Australia.
The findings, published in leading medical journal The Lancet, question the universal endorsement of paracetamol as the first choice for pain relief medication for this condition, say the authors.
The study randomly allocated 1652 patients with acute lower back pain from 235 primary care centres in Sydney to receive one of the following three treatments:
- up to four weeks of paracetamol in regular doses (three times a day; equivalent to 3990mg per day)
- paracetamol as needed (maximum 4000 mg per day)
All participants received advice and reassurance and were followed up for three months.
No statistical difference between treatment groups
The median time to recovery from an acute episode of lower back pain was 17 days in the regular paracetamol group, 17 days in the as-needed paracetamol group, and 16 days in the placebo group – in other words, there was no statistical difference between the treatment groups. Paracetamol also had no effect on short-term pain levels, disability, function, sleep quality, or quality of life. The number of participants reporting adverse events was similar between the groups.
"Simple analgesics such as paracetamol might not be of primary importance in the management of acute lower back pain", says lead author Dr Christopher Williams from the George Institute for Global Health at the University of Sydney.
"The results suggest we need to reconsider the universal recommendation to provide paracetamol as a first-line treatment for lower back pain," says Williams.
According to senior author Associate Professor Christine Lin, also of The George Institute, the reasons for paracetamol failing to work for sudden low-back pain are not well understood.
"While we have shown that paracetamol does not speed recovery from sudden, acute back pain, there is evidence that paracetamol works to relieve pain for a range of other conditions, such as headaches, some acute musculoskeletal conditions, toothache and for pain straight after surgery. Paracetamol is also effective in reducing fever. What this study indicates is that the mechanisms of back pain are likely to be different from other pain conditions, and this is an area that we need to study more," Lin says.
In this study 50% of all participants fully recovered by two-and-a-half weeks – a faster improvement than what is observed in people receiving 'usual care'.
"Our trial doctors followed the treatment guideline and provided reassurance and advice to stay active to participants. Surprisingly, it may be that it is what the doctor says to a patient with back pain, rather than the analgesic they prescribe, that is most important for aiding recovery," adds Lin.
Lower back pain is the leading cause of disability worldwide. Back problems in Australia cost $4.8bn, or 8.7% of Australia's health budget.
Treating acute low back pain – other options
With acute back pain, it's important to remain as active as possible and avoid bed rest, according to Associate Professor Lin.
"An active approach is probably more important than any therapy [a person] may receive. Heat wraps and heat packs are simple methods that the person can use to help with their pain.
"If that simple approach does not help you can talk to your pharmacist or doctor about other pain medicines, but you do need to carefully follow their advice as these medicines can have serious side effects. There is also some evidence that a short course of spinal manipulation can help control pain," she says.
GPs 'too quick' to order imaging tests for back problems
In separate back pain news a study, carried out by the University of Sydney, researchers found GPs are too quick to order diagnostic imaging tests for back problems. Expert guidelines advise caution in ordering tests during the initial assessment of back problems unless there's a red flag – such as major trauma or history of malignancy – to prompt further investigation. But the study found GPs are twice as likely to order an imaging test during the initial examination of new back problems compared to follow-up consultation, despite 'red flag' patients only accounting for a small proportion of people presenting with new back problems, suggesting some unnecessary use of imaging tests.