Yes, that oh so common complaint that brings patients into the ER. With acute back pain, everyone seems to have their own cocktail for treatment, but what has been shown to work? In this reviewed of a trial in JAMA published October 20, 2015 we review a randomized control trial that looked into just this issue.
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Title: Naproxen with Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Control Trial
Case: A 26 y/o otherwise healthy male comes to your ED complaining of back pain after moving furniture at his home. He reports pain that is worse with lifting, bending, and twisting that is mostly a dull ache but sharp at times. At home he has tried ice and heat without relief. His review of systems is negative for red flag symptoms. On exam he has tenderness to palpation of the lower back without vertebral point tenderness and occasional muscle spasms are palpated.
Background: Low back pain is a common complaint that is responsible for more than 2.5 million visits annually. It is treated in a variety of ways ranging NSAIDS to muscle relaxers, and even opiates.
Clinical Question: In patients with acute, nontraumatic, nonradicular low back pain presenting to the ED, does adding cyclobenzaprine or oxycodone/acetaminophen to naproxen improve functional outcomes or pain at one week follow-up?
Author’s Conclusions: Among patients with acute, nontraumatic, nonradicular low back pain presenting to the ED, adding cyclobenzaprine or oxycodone/acetaminophen to naproxen did not improve functional outcomes or pain at one week follow-up. These findings do not support use of these additional medications in this setting.
Quality Checklist for Randomized Clinical Trials:
Key Results: RMDQ at baseline in the placebo group was 20 (interquartile range [IQR] of 17-21), in the cyclobenzaprine group 19 (IQR of 17-21), and oxycodone/acetaminophen group 20 (IQR 17-22). AT one week follow-up the RMDQ improvement was 9.8 in the placebo group, 10.1 in the cyclobenzaprine group, and 11.1 in the oxycodone/acetaminophen group. Between-group difference in the mean RMDQ improvement for cyclobenzaprine vs placebo was 0.3 (98.3% CI, -2.6 to 3.2 with a p=0.77), for oxycodone/acetaminophen vs placebo 1.3 (98.3% CI, -2.1 to 3.9 with a p=0.45), and oxycodone/acetaminophen vs cyclobenzaprine was 0.9 (98.3% CI, -2.1 to 3.9 with a p=0.45).
Key Points of Debate:
We agree with the conclusion that patients with acute, nontraumatic, nonradicular low back pain presenting to the ED do not benefit from adding cyclobenzaprine or oxycodone/acetaminophen to naproxen to improve functional outcomes or pain at one week. Routine use of adding these medications do not appear to be useful based on this study. However, this is a narrow population and cannot be generalized to all back pain patients.
Our Bottom Line:
We agree the addition of cyclobenzaprine or oxycodone/acetaminophen does not show benefit in addition to naproxen for acute, nontraumatic, nonradicular low back pain of less than two weeks duration.
You discuss with your patient the plan for treatment. You review how current evidence shows that naproxen alone appears beneficial and medications such as cyclobenzaprine or oxycodone/acetaminophen do not show additional benefit. You also explain how added these other medications do have increased risks such as drowsiness, nausea/vomiting, and dizziness. After this shared decision making, the patient agrees to try naproxen along with conservative measures to help with his pain.
At this time, patients who are appropriate and meet study criteria should be considered for treatment by naproxen alone. Shared decision making and detailed information about back pain along with the risks/benefits of other potential medications should be discussed.
What do I tell my patient?
Although there are many ways to treat back pain, our current evidence shows that naproxen alone is beneficial in treating your pain. Other medications have been tested with naproxen and do not show benefit. Back pain can take a long time to recover from and there are many ways to help speed your recovery. Make sure to follow-up with your PCP so that they can further evaluate your pain with time to see if other things need to be done.
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