Skip to main content

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

Abstract

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.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  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 Hills

    Google 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

    PubMed  Article  Google 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

    PubMed  Article  Google 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, Paris

    Google 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 7:1–76

    PubMed  CAS  Google Scholar 

  6. 6.

    Gow P, Griffiths R, Grimes P et al (2004) New Zealand acute low back pain guide. ACC, Wellington

    Google 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

    PubMed  Article  Google Scholar 

  8. 8.

    Hackett GI, Seddon D, Kaminski D (1988) Electroacupuncture compared with paracetamol for acute low back pain. Practitioner 232:163–164

    PubMed  CAS  Google Scholar 

  9. 9.

    Hickey RF (1982) Chronic low back pain: a comparison of diflunisal with paracetamol. N Z Med J 95:312–314

    PubMed  CAS  Google 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 http://www.cochrane-handbook.org

  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

    PubMed  Article  CAS  Google 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 83:713–721

    PubMed  Google 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 6:187–193

    PubMed  CAS  Article  Google Scholar 

  14. 14.

    Miller G (1956) The magical number seven, plus or minus two. Psychol Rev 63:81–97. doi:10.1037/h0043158

    PubMed  Article  CAS  Google 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

    PubMed  Article  Google 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

    PubMed  Article  CAS  Google 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 37:63–70

    PubMed  CAS  Google 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

    PubMed  Article  Google 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

    PubMed  Article  Google 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

    PubMed  Article  CAS  Google Scholar 

Download references

Acknowledgments

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.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Christopher G. Maher.

Appendix

Appendix

Search strategies (adapted from van Tulder et al. [19])

Medline—Ovid Medline

01. randomized controlled trial.pt, 02. controlled clinical trial.pt, 03. Randomized Controlled Trials/, 04. Random Allocation/, 05. Double-Blind Method/, 06. Single-Blind Method/, 07. or/1–6, 08. Animal/not Human/, 09. 7 not 8, 10. clinical trial.pt, 11. explode Clinical Trials/, 12. (clinic$ adj25 trial$).tw, 13. ((singl$ or doubl$ or treb$ or tripl$) adj (mask$ or blind$)).tw, 14. Placebos/, 15. placebo$.tw, 16. random$.tw, 17. Research Design/, 18. (latin adj square).tw, 19. or/10–18, 20. 19 not 8, 21. 20 not 9, 22. Comparative Study/, 23. explode Evaluation Studies/, 24. Follow-Up Studies/, 25. Prospective Studies/, 26. (control$ or prospective$ or volunteer$).tw, 27. Cross-Over Studies/, 28. or/22–27, 29. 28 not 8, 30. 29 not (9 or 21), 31. 9 or 21 or 30, 32. low back pain/, 33. low back pain.tw, 34. backache.tw, 35. lumbago, 36. or/32–35, 37. paracetamol.tw, 38. paracetamol/, 39. acetaminophen.tw, 40. acetaminophen/, 41. APAP.tw, 42. APAP/, 43. chemadol.tw, 44. duatrol.tw, 45. dymadon.tw, 46. febridol.tw, 47. panadol.tw, 48. panamax.tw, 49. parahexal.tw, 50. paralgin.tw, 51. parmol.tw, 52. perfalgan, 53. tylenol.tw, 54. or/37–53, 55. 31 and 36 and 54.

CINAHL—Ovid CINHAL

01. randomized controlled trial.pt, 02. controlled clinical trial.pt, 03. Randomized Controlled Trials/, 04. Random Assignment/, 05. Double-Blind Studies/, 06. Single-Blind Studies/, 07. or/1–6, 08. Animal/not Human/, 09. 7 not 8, 10. clinical trial.pt, 11. exp Clinical Trials/, 12. (clinic$ adj25 trial$).tw, 13. ((singl$ or doubl$ or treb$ or tripl$) adj (mask$ or blind$)).tw, 14. Placebos/, 15. placebo$.tw, 16. random$.tw, 17. Research Design/, 18. (latin adj square).tw, 19. or/10–18, 20. 19 not 8, 21. 20 not 9, 22. Comparative Study/, 23. exp Evaluation Studies/, 24. Follow-Up Studies/, 25 Prospective Studies/, 26. (control$ or prospective$ or volunteer$).tw, 27. Cross-Over Design/, 28. or/22–27, 29. 28 not 8, 30. 29 not (9 or 21), 31. 9 or 21 or 30, 32. low back pain/, 33. low back pain.tw, 34. backache.tw, 35. lumbago, 36. or/32–35, 37. paracetamol.tw, 38. paracetamol/, 39. acetaminophen.tw, 40. acetaminophen/, 41. APAP.tw, 42. APAP/, 43. chemadol.tw, 44. duatrol.tw, 45. dymadon.tw, 46. febridol.tw, 47. panadol.tw, 48. panamax.tw, 49. parahexal.tw, 50. paralgin.tw, 51. parmol.tw, 52. perfalgan, 53. tylenol.tw, 54. or/37–53, 55. 31 and 36 and 54.

Embase—EMBASE.com

(‘low back pain’ or ‘backache’ or lumbago’) and (‘paracetamol’ or ‘acetaminophen’ or ‘APAP’ or ‘chemadol’ or ‘duatrol’ or ‘dymadon’ or ‘febridol’ or ‘panadol’ or ‘panamax’ or ‘parahexal’ or ‘paralgin’ or ‘parmol’ or ‘perfalgan’ or ‘tylenol’).

Selecting the following limits: “Map to preferred terminology”, “Also search as free text”, “Include sub-terms/derivatives”, “All Years”, “Humans”, “EMBASE only”, “Controlled Clinical Trial” and “Randomized Controlled Trial”.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Davies, R.A., Maher, C.G. & Hancock, M.J. A systematic review of paracetamol for non-specific low back pain. Eur Spine J 17, 1423 (2008). https://doi.org/10.1007/s00586-008-0783-x

Download citation

Keywords

  • Low back pain
  • Paracetamol
  • Acetaminophen
  • Review