Back to basics

Behind the Headlines

Friday November 9 2007

Picture of a spine

Take paracetamol and keep moving

Simple painkillers are better than spinal manipulation or anti-inflammatory drugs to cure a bad back, reported The Daily Telegraph and other newspapers. “Visiting a chiropractor for a bad back may be a waste of time and money,” the newspaper said. The Daily Mail adds, “Patients get better just as quickly if they simply stay active and take a mild painkiller such as paracetamol.”

The story is based on a well-conducted study in people who had persistent, acute, mild back pain. The researchers compared stronger painkillers and spinal manipulation with continued conservative treatment (paracetamol and advice about avoiding bed rest and remaining active and so on). The study suggests that neither spinal manipulation nor strong painkillers are more effective than conservative treatment including paracetamol for acute back pain.

Where did the story come from?

Dr Mark Hancock and colleagues from the University of Sydney conducted this research. The study was funded by Australia’s National Health and Medical Research Council and was published in the peer-reviewed medical journal The Lancet.

What kind of scientific study was this?

This was a randomised controlled trial comparing four different types of treatment in 240 people. All of the participants had already seen their GP about their back pain and had been given advice and paracetamol to treat it. The patients were then randomised to:

  • diclofenac (an anti-inflammatory painkiller) and sham (fake) manipulation therapy,
  • spinal manipulation therapy and a placebo drug,
  • both diclofenac and spinal manipulation, or 
  • placebo drug and sham manipulation.

Diclofenac (50mg) was given twice daily and spinal manipulation treatment took place two or three times a week, to a maximum of 12 treatments in four weeks. The sham manipulation therapy was performed using detuned ultrasound (which means ultrasound treatment that is not genuine, i.e. a placebo). This type of sham treatment was used so that the time spent and the contact with the physiotherapist was the same for all the groups.

There is no additional benefit from stronger anti-inflammatory painkillers or spinal manipulation

The participants completed a daily pain diary where they rated their pain that day on a scale of 0 (no pain) to 10 (maximum pain). The researchers compared the groups using “time to recovery”; this was defined as either the first pain-free day (i.e. a score of 0), or the first seven consecutive days in which the patient had a pain score of 0 or 1. Participants were contacted by telephone at weeks 1, 2, 4 and 12 to collect their pain scores. Any side effects experienced by the participants were also recorded at these time points.


What were the results of the study?

The study found that there was no difference between the groups in terms of time to recovery. This means that receiving additional treatment (anti-inflammatory drugs, spinal manipulation or both) appeared to be no better than continuing to follow advice to stay active and to take paracetamol (which is the recommended way to treat acute back pain in the first instance). All groups took between 13 and 16 days to recover from their acute back pain.


What interpretations did the researchers draw from these results?

The researchers conclude that when “quality baseline care is provided” (giving advice about remaining active, avoiding bed rest and taking paracetamol), there is no additional benefit from stronger anti-inflammatory painkillers or spinal manipulation.

What does the NHS Knowledge Service make of this study?

The findings of this study may have implications for policies on treating back pain with spinal manipulation. International guidelines recommend treatment with advice and paracetamol first, then anti-inflammatory drugs and spinal manipulation if that's not effective. There are a some points to keep in mind when interpreting the results, but overall the study suggests that anti-inflammatory drugs or spinal manipulation or both do not reduce time to recovery when compared with continuing with standard initial care (i.e. advice and paracetamol).

  • As the study was conducted in Australia, there may be some issues with generalising the findings to the way spinal manipulation is delivered in the UK.
  • The spinal manipulation in this study was conducted by trained physiotherapists (not chiropractors, as the news stories might imply). Importantly, spinal manipulation was not associated with any serious side effects. 
  • Participants were not completely compliant about taking painkillers. They took about two-thirds of the prescribed dose of paracetamol and about 70% of the prescribed diclofenac dose. However, compliance rates did not differ between the groups (i.e. they're not likely to have affected the relative treatment effects found in the study).
  • The chiropractic and physiotherapy treatment experience is not just about manipulation; it also includes lifestyle advice and advice about posture, rehabilitation and specific exercises. The study addressed only the manipulation part of this package and did not assess the benefits of these other aspects.

For people with simple back pain – a common and debilitating condition – it may seem intuitive that more intensive treatments should be tried in people who do not respond to simple measures. This study challenges that thought and adds to the mounting evidence that simple painkillers, staying active and allowing time to heal are best for most people.


Sir Muir Gray adds...

In general, use as little medicine as possible, delay using medicine to see if you will get better, then give the simplest medicine a good shot before seeking more intensive treatments.


Analysis by Bazian

Edited by NHS Choices

Links to the headlines

Chiropractors 'are waste of money'. The Daily Telegraph, November 9 2007

Chiropractors may be a waste of time. Daily Mail, November 9 2007

Chiropractors may be no use in treating back pain. The Guardian, November 9 2007

Painkillers and a walk are best for back pain. The Times, November 9 2007

'Paracetamol and reassurance' are all it takes to cure a bad back. The Independent, November 9 2007

Simple therapy best for back pain. BBC News, November 9 2007

Links to the science

Original source Hancock MJ, Maher CG, Latimer J, 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

Further reading van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low-back pain. Cochrane Database Syst Rev 2003, Issue 4


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