Written by Clay Smith
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There was no benefit in functional outcome or pain at one week by using ibuprofen + either baclofen, metaxolone, or tizanidine over ibuprofen + placebo.
Why does this matter?
A metaanalysis showed muscle relaxers may be marginally helpful for low back pain. But individual RCTs have shown no benefit for diazepam, orphenadrine or methocarbamol, or cyclobenzaprine. What about a head-to-head trial of several other agents compared to placebo? Surely one of these will help, right?
Time found to be most effective therapy for back pain
This was a multifactorial RCT with 320 patients randomized to ibuprofen + either placebo, baclofen, metaxolone, or tizanidine. For the primary outcome of improved functional disability at one week, there was no difference, nor was there improvement in pain with any of the active muscle relaxers compared to ibuprofen + placebo. Prescriptions for muscle relaxers may make me feel better, like I’m helping, but they don’t actually help the patient. It’s kind of a bummer.
Source
A Randomized, Placebo-Controlled Trial of Ibuprofen Plus Metaxalone, Tizanidine, or Baclofen for Acute Low Back Pain. Ann Emerg Med. 2019 Apr 5. pii: S0196-0644(19)30139-8. doi: 10.1016/j.annemergmed.2019.02.017. [Epub ahead of print]
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Reviewed by Thomas Davis
This is an example of EBM missing the point of patient care. As an EM physician with a long history of intermittent exacerbations of severe lower back pain, I recognize that there may be no difference at 1 week between NSAID alone or NSAID + a muscle relaxant. But there is a definite difference in the severity of my pain on days 1 through 6; and I have had several patients reinforce that difference. So we need to decide if we care more about our quantifiable evidenced endpoint, or that subjective endpoint of patient suffering. Take my baclofen away and I will hunt you down!
I hear you. Sometimes the pain is really severe, and these agents at least make patients sleepy. I usually prescribe them only at bedtime. Maybe a reasonable compromise is to tell patients, "This may not drastically reduce your pain a week out, but at least you will be able to sleep." Just don’t want to get hunted down!