European Spine Journal

, 17:1423 | Cite as

A systematic review of paracetamol for non-specific low back pain

  • Reece A. Davies
  • Christopher G. MaherEmail author
  • Mark J. Hancock


The objective of this study was to assess the efficacy of paracetamol (acetaminophen) in the treatment of pain and disability in patients with non-specific low back pain. We conducted a systematic review of randomized controlled trials to assess the efficacy of paracetamol in the treatment of pain and disability in patients with non-specific low back pain. A search for randomized controlled trials was conducted using the Medline, Embase and CINAHL databases. Trials were eligible if they were randomized controlled trials comparing paracetamol to no treatment, placebo or another treatment in patients with non-specific low back pain. Two of the authors independently assessed trials for methodological quality on the PEDro Scale and extracted data. Continuous pain and disability data were converted to a common 0–10 scale; ordinal data were dichotomized (e.g., no pain, pain). The data was analyzed using the MIX version 1.61 meta-analysis software. Out of 205 unique articles found in the searches, 7 eligible trials were identified. The trials enrolled a total of 676 participants with 5 investigating acute low back pain, 1 investigating chronic low back pain and 1 investigating both. No trial provided data comparing paracetamol to placebo and only one trial compared paracetamol to no treatment. In general the trials were small (only 1 trial had >25 subjects per group) and of low methodological quality (only 2 had a score above 6 on the quality scale). All but one of the trials provided imprecise estimates of the effects of treatment with confidence intervals spanning clinically important beneficial and also harmful effects of paracetamol. No trial reported a statistically significant difference in favor of paracetamol. There is insufficient evidence to assess the efficacy of paracetamol in patients with low back pain. There is a clear need for large, high quality randomized controlled trials evaluating paracetamol, to provide reliable evidence of paracetamol’s effectiveness in patients with low back pain and to establish the validity of the recommendations in clinical guidelines.


Low back pain Paracetamol Acetaminophen Review 



The authors would like to thank A/Professor Jane Latimer for critical review of the study protocol, A/Professor Rob Herbert for his assistance with statistical analyses and Brendan Wilson and Grant Mackay for assistance with proof reading of the manuscript. Chris Maher’s Research Fellowship is funded by the National Health and Medical Research Council of Australia. Mark Hancock’s Primary Care Post Graduate Scholarship was funded by the National Health and Medical Research council of Australia.


  1. 1.
    Australian Acute Musculoskeletal Pain Guidelines Group (2003) Evidence-based management of acute musculoskeletal pain: a guide for clinicians. Australian Academic Press Pty Ltd., Bowen HillsGoogle Scholar
  2. 2.
    Bax L, Yu L-M, Ikeda N, Tsuruta H, Moons KGM (2006) Development and validation of MIX: comprehensive free software for meta-analysis of causal research data. BMC Med Res Methodol 6:50. doi: 10.1186/1471-2288-6-50 PubMedCrossRefGoogle Scholar
  3. 3.
    Bhogal SK, Teasell RW, Foley NC, Speechley M (2005) The PEDro scale provides a more comprehensive measure of methodological quality than the Jadad scale in stroke rehabilitation literature. J Clin Epidemiol 58:668–673. doi: 10.1016/j.jclinepi.2005.01.002 PubMedCrossRefGoogle Scholar
  4. 4.
    Delcambre B, Jeantet M, Laversin S et al (2000) Diagnosis, management and follow-up of patients with chronic low back pain (quick reference guide for clinicians). Agence Nationale d’Accréditation et d’Évaluation en Santé, ParisGoogle Scholar
  5. 5.
    Egger M, Bartlett C, Holenstein F, Sterne J (2003) How important are comprehensive literature searches and the assessment of trial quality in systematic reviews? Empirical study. Health Technol Assess 7:1–76PubMedGoogle Scholar
  6. 6.
    Gow P, Griffiths R, Grimes P et al (2004) New Zealand acute low back pain guide. ACC, WellingtonGoogle Scholar
  7. 7.
    Graham GG, Scott KF (2005) Mechanism of action of paracetamol. Am J Ther 12:46–55. doi: 10.1097/00045391-200501000-00008 PubMedCrossRefGoogle Scholar
  8. 8.
    Hackett GI, Seddon D, Kaminski D (1988) Electroacupuncture compared with paracetamol for acute low back pain. Practitioner 232:163–164PubMedGoogle Scholar
  9. 9.
    Hickey RF (1982) Chronic low back pain: a comparison of diflunisal with paracetamol. N Z Med J 95:312–314PubMedGoogle Scholar
  10. 10.
    Higgins JPT, Green S (eds) (2008) Cochrane handbook for systematic reviews of interventions version 5.0.0. The Cochrane Collaboration. Available from
  11. 11.
    Koes BW, van Tulder MW, Ostelo R, Burton K, Waddell G (2001) Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 26:2504–2513. doi: 10.1097/00007632-200111150-00022 PubMedCrossRefGoogle Scholar
  12. 12.
    Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M (2003) Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther 83:713–721PubMedGoogle Scholar
  13. 13.
    Milgrom C, Finestone A, Lev B, Wiener M, Floman Y (1993) Overexertional lumbar and thoracic back pain among recruits: a prospective study of risk factors and treatment regimens. J Spinal Disord 6:187–193PubMedCrossRefGoogle Scholar
  14. 14.
    Miller G (1956) The magical number seven, plus or minus two. Psychol Rev 63:81–97. doi: 10.1037/h0043158 PubMedCrossRefGoogle Scholar
  15. 15.
    Nadler SF, Steiner DJ, Erasala GN et al (2002) Continuous low-level heat wrap therapy provides more efficacy than ibuprofen and acetaminophen for acute low back pain. Spine 27:1012–1017. doi: 10.1097/00007632-200205150-00003 PubMedCrossRefGoogle Scholar
  16. 16.
    Schulz K, Chalmers I, Hayes R, Altman D (1995) Empirical evidence of bias: dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 273:408–412. doi: 10.1001/jama.273.5.408 PubMedCrossRefGoogle Scholar
  17. 17.
    Stein D, Peri T, Edelstein E, Elizur A, Floman Y (1996) The efficacy of amitriptyline and acetaminophen in the management of acute low back pain. Psychosomatics 37:63–70PubMedGoogle Scholar
  18. 18.
    Van Tulder M, Becker A, Bekkering T, Breen A, Gil del Real MT, Hutchinson A et al (2006) European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J 15:S169–S191. doi: 10.1007/s00586-006-1071-2 PubMedCrossRefGoogle Scholar
  19. 19.
    van Tulder M, Furlan A, Bombardier C, Bouter L, The Editorial Board of the Cochrane Collaboration Back Review Group (2003) Updated method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group. Spine 28:1290–1299. doi: 10.1097/00007632-200306150-00014 PubMedCrossRefGoogle Scholar
  20. 20.
    Wiesel SW, Cuckler JM, Deluca F, Jones F, Zeide MS, Rothman RH (1980) Acute low-back pain. An objective analysis of conservative therapy. Spine 5:324–330. doi: 10.1097/00007632-198007000-00006 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Reece A. Davies
    • 1
  • Christopher G. Maher
    • 2
    • 3
    Email author
  • Mark J. Hancock
    • 1
  1. 1.Back Pain Research GroupUniversity of SydneySydneyAustralia
  2. 2.Musculoskeletal DivisionThe George Institute for International HealthSydneyAustralia
  3. 3.Faculty of MedicineUniversity of SydneySydneyAustralia

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