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Overviews and Systematic Reviews on Low Back Pain
- Jan M. Bjordal, MPT, PhD;
- Atle Klovning, MD;
- Rodrigo Alvaro B. Lopes-Martins, MPharm, PhD;
- Pål-Didrik Hoff Roland, MPharm;
- Jon Joensen, MPT; and
- Lars Slørdal, MD, PhD
- From Bergen University College, 5009 Bergen, Norway; University of Oslo, 0318 Oslo, Norway; University of São Paulo, 05508-900 São Paulo, Brazil; St. Olavs Hospital, 7006 Trondheim, Norway; University of Bergen, 5018 Bergen, Norway; and Norwegian University of Science and Technology, 7489 Trondheim, Norway.
TO THE EDITOR:
In a recent overview of systematic reviews and randomized trials of pharmacotherapy in low back pain, Chou and Huffman (1) concluded that there is good evidence that acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants provide moderate pain relief in acute low back pain. In the clinical practice guideline (2) in the same issue, the recommendations for acetaminophen and NSAIDs are extended to include chronic low back pain and tramadol, opioids, and benzodiazepines are recommended both in acute and chronic low back pain despite lack of “good” or even “fair” evidence. Chou and Huffman's method of reviewing literature relies too heavily on preexisting systematic reviews, some seriously outdated. As a result, previous work is reiterated without adequate scrutiny. In fact, methodological issues led to inclusion of studies not meeting the stated eligibility criteria and, more important, to erroneous conclusions.
Acetaminophen: No direct evidence shows acetaminophen to be more effective than placebo for treating low back pain. A small (n = 30) trial (3) found acetaminophen to be less effective than NSAIDs in treating acute low back pain. One low-quality trial (4) reported no difference between acetaminophen and no treatment, and another (5) showed ambiguous results. In an outdated Cochrane review (6) cited by Chou and Huffman, 2 low-quality trials (7, 8) found no difference between NSAIDs and acetaminophen. One of these trials (7) was not randomized. Comparative studies (9) of acetaminophen and nonpharmacologic treatments in high-quality randomized, controlled trials (RCTs) have shown that acetaminophen was inferior to superficial heat. In an old trial of lower quality (10), acetaminophen allegedly was slightly inferior to …
