Low Back Pain: Are We Offering Too Much?

Abstract & Commentary

By Joseph E. Safdieh, MD, Assistant Professor of Neurology, Weill Medical College, Cornell University. Dr. Safdieh reports no financial relationships relevant to this field of study.

Synopsis: Patients with acute low back pain receiving acetaminophen and standard advice do not benefit from the addition of NSAIDs or spinal manipulative therapy.

Source: Hancock MJ, Maher CG, et al. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. Lancet 2007;370:1638-1643.

Acute low back pain is a common chief complaint in general practice as well as in neurology. Treatment guidelines for acute low back pain at this time recommend using acetaminophen and advising patients of moderate physical activity and avoidance of bed rest. Many physicians prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) and/or spinal manipulative therapy for acute low back pain. This study was designed to assess whether NSAIDs or spinal manipulative therapy would result in faster recovery when used in addition to acetaminophen and patient teaching.

The trial enrolled 240 patients with moderate, non-radiating, or radiating low back pain of less than six weeks duration presenting to general practitioners in Australia. Of note, patients with two or more radicular findings on examination (including myotomal weakness, dermatomal sensory loss, or reflex loss) were excluded. All patients were given paracetamol 1 gram four times daily and standard advice. Patients were subsequently randomized into four groups: spinal manipulation plus diclofenac, placebo manipulation plus diclofenac, spinal manipulation plus placebo diclofenac, or placebo manipulation plus placebo diclofenac. Placebo spinal manipulation was carried out with detuned pulsed ultrasound. Active spinal manipulation was delivered using joint mobilization and high velocity thrust procedures that could be adjusted at the therapist's judgment depending on the clinical presentation. Primary outcome was the number of days to recovery.

The results of the study demonstrated that neither diclofenac nor spinal manipulation therapy used individually or in combination significantly hastened recovery time. Across all groups, the median time to recovery was approximately 2 weeks. Of the patients, 99% recovered completely by 12 weeks after randomization. Neither diclofenac nor spinal manipulation therapy had a significant effect on any of the secondary outcomes, which included pain, disability, daily functioning, or global perceived effect. No statistically significant differences in adverse reactions were noted in this trial. One patient had a hypersensitivity reaction to diclofenac.


This study demonstrates a generally well-known fact about acute radiating or nonradiating back pain: it is almost always self-limiting. The study suggests that NSAIDs and spinal manipulation do not really offer any benefit over basic counseling and acetaminophen. General practitioners and other physicians encountering these patients have further evidence that conservative management is indeed appropriate as long as there is no evidence of significant nerve root compression on neurological examination. Patients with acute low back pain should be offered reevaluation at four weeks time if the symptoms are not resolved. In the small group of patients in whom pain persists at four weeks, modalities such as imaging, spinal manipulative therapy, and NSAIDs could be discussed.