Last week’s Inside Health programme on Radio 4 looked at new research which suggests that doctors have been getting it wrong when it comes to treating bad backs. The largest trial to date of paracetamol for back pain provides strong evidence that Britain’s most popular painkiller doesn’t actually help the condition at all.
The programme concluded that the best way to treat a bad back is to keep as active as possible, and do exercises like Pilates to help manage the pain and over time, strengthen and mobilise the muscles, ligaments and tendons that support and move the spine.
Below is a transcript of the relevant section of the programme, a discussion between the presenter of Inside Health, Dr Mark Porter, Esther Williamson, a Research Fellow at the University of Oxford and Margaret McCartney, a GP in Glasgow.
Williamson: This research looked at the use of paracetamol for patients who went to their GP, physio or chiropractor with an acute episode of low back pain. They essentially evaluated the use of paracetamol in this patient group because paracetamol is the first drug of choice in all the international guidelines for the management of acute or a recent onset low back pain. They found that whether you took paracetamol regularly or as you needed it, it was no better than just taking a placebo or a dummy pill and that it didn’t help people to recover better or impact their pain or their disability levels.
Porter: Basically it didn’t work.
Porter: So how did it get into the guidelines in the first place? One would like to think that they were evidence based. Is this the first time someone’s actually looked at this?
Williamson: No, it’s not the first time it’s been looked at, but certainly the studies to date have been a lot smaller than this so that’s really one of the strengths of this research – it’s a really large study with 1600 patients, so we can be confident of the findings. I think the total sum of participants who’d been involved in previous research was only about half that number, so the previous studies weren’t as good quality. When guidelines are made, people need to make decisions on the best available evidence, so they also drew from evidence in other conditions as well, so things like post-operative pain and headache where paracetamol had been shown to be effective.
Porter: A lot of people listening to this may find the fact a painkiller doesn’t help back pain as counter-intuitive. Why do we think paracetamol is not effective?
Williamson: We’re not entirely sure because it has been shown to be effective in the other conditions I mentioned. So the big question then is really why is back pain different to other sorts of pain? We don’t actually know the answer to that. Paracetamol is very good at reducing fever and we know that there’s obviously no fever when you present with acute low back pain. It’s thought that maybe it does work on some of the chemicals released during the inflammation process. Perhaps people who come in with episodes of low back pain don’t actually have a lot of inflammation in their tissues, so that’s another reason why it doesn’t work. But obviously it is quite confusing because anti-inflammatories are also used for acute low back pain, which would be working via that mechanism, so I think the simple answer is that we really don’t know.
Porter: Let’s be clear about what the study found. The study showed that paracetamol had no benefit over placebo.
Williamson: That’s right.
Porter: But did the placebo itself have a significant benefit?
Williamson: Yes. All the patients in this study recovered really well, so by about 12 weeks, 85% of the patients had recovered and this is actually a lot better than a lot of other previously published back pain studies. So you could say that actually the placebo tablet worked just as well as the paracetamol. And I have heard some suggestions – well if that’s the case what does it matter if people take paracetamol if it seems to be working even if it’s just as a placebo? My answer to that is patients shouldn’t be taking medicine that we know isn’t affecting them just as a placebo. The other important thing about this study was that all the patients had a session with a health professional where they were given advice about their back pain, about not resting, about staying active and continuing their normal daily activities, given reassurance that back pain is not serious and that most people recover well. And the authors also raised the point that maybe actually this element of the treatment was really important to these patients, so the patients who got the placebo drug also got this advice and maybe that’s what facilitated the good recovery within the group.
Porter: Do you think we’ll see a change in the guidelines accordingly, given that this is such a large study?
Williamson: It has been suggested by some people in the field that it’s too soon to change the guidelines, that it shouldn’t be changed just on the basis of one study. But it is a really big study, it’s a well conducted study and if you look at the patients that appear in it, they do seem similar to, say the patients that would present to primary care within the UK. So it’s possible that people will ask for this to be replicated in another country, just to confirm the findings, but really on the basis of this study alone, I would say serious consideration does need to be given to the guidelines.
Porter: GP Margaret McCartney is in our Glasgow studio and has been listening to this discussion. Margaret, Esther made the point that advice is a key part of managing simple back pain, but much of that is counter-intuitive too?
McCartney: Absolutely and I think what we know more than anything is that time and time again we keep getting it wrong with the management of back pain. When I was a medical student I clearly remember going to see a patient in his home where he was going through the standard treatment for low back pain, which was lying on a hard board 24 hours a day for about a week. God only knows how much harm that did, but that kind of thing was very much in standard practice then and we now know that that’s one of the worst things you can do for back pain. You want to keep as mobile as you possibly can. But it took a long time for that evidence to come through, contrary to the amount of time that we spent giving people the wrong advice.
Porter: The cynic in me wonders what happens if we do nothing. What happens if we just tell a patient that they’ve got simple back pain and it’s going to get better and send them away?
McCartney: This is the big question and one that hasn’t been properly addressed in this trial, through no fault of their own, but what I think we really need to get is more of these so-called three armed trials where you don’t just compare a placebo to the active drug, the paracetamol, but you have another group where you don’t use any tablets at all, but you use the same good advice that was used for all the other patients in terms of telling someone that their back pain is likely to get better anyway, that their activity levels should try and remain up because that is going to help them. We give them all the usual advice, reassurance and information about back pain and its normal pattern so that we can find out what the actual effect is of the tablet. Do you actually need the tablet to get the placebo effect, or can you get the placebo effect, that caring effect, through other means, through information, advice and physical activity. And that’s the big question because the problem is that the placebo effect is real, people do get a benefit from placebos but I don’t have any placebos to prescribe to give people that effect without the paracetamol in it.
Porter: What would you prescribe to someone then who came to see you now with back pain that’s bothering them enough, say to keep them awake at night. What sort of medicines are you going to use?
McCartney: Well for the kind of typical pain we’re talking about here, someone that’s got acute back pain, that’s short term rather than long term, I think the first thing to do is to take a history, talk to your patient, find out what’s going on and what they would like and what they would want. I think a lot of people are probably not going to want paracetamol after this, that there is some evidence that says anti-inflammatories are better than placebo for low back pain, so we could offer that…
Porter: These are ibuprofen type drugs?
McCartney: Things like ibuprofen, but they have a different side effect profile – gastric irritation being one of them. They’re also not great with a lot of other drugs, so that’s another consideration. But the big recommendation for me would be to keep active, we’ve got lots of exercise sheets we can use, we’ve got physiotherapists we can call on too. My best advice would be to try and keep active as much as you can and of course to return and see us if things are not improving as we’d expect them to.