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Should We Add Muscle Relaxants to Ibuprofen for Acute Low Back Pain?

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Authors: Friedman BW et al.

Ann Emerg Med 2019 Apr 5

A high-quality study of three muscle relaxants confirms what most of us already know: They don’t help.

Despite a lack of evidence of efficacy, skeletal muscle relaxants are commonly used to treat back pain in conjunction with nonsteroidal anti-inflammatory drugs (NSAIDs). Researchers at two emergency departments in the Bronx evaluated three muscle relaxants in a randomized, double-blind trial. A total of 320 patients received either placebo or one of the three study drugs (baclofen, 10–20 mg; metaxalone, 400–800 mg; or tizanidine, 2–4 mg) in addition to ibuprofen (600 mg) every 8 hours for 7 days. The median functional disability score at baseline was 19 on a validated 24-item scale.

At 1 week, there was no significant difference between groups in the primary outcome — improvement in functional disability score (mean improvement, about 11 points) — or any secondary outcome, including level of pain and time to return to work. Adverse events did not differ between groups, and none were serious.

COMMENT by Benton R. Hunter, MD

The absence of benefit is not surprising, especially given previous studies demonstrating no benefit from the addition of other medications (e.g., diazepam, cyclobenzaprine, oxycodone) to NSAIDs, and some evidence suggests that NSAIDs are also of questionable benefit (NEJM JW Gen Med Sep 1 2017 and Ann Rheum Dis 2017; 76:1269). Muscle relaxants for back pain are like antibiotics for cough: They rarely, if ever, help, but sometimes prescribing them seems like the path of least resistance. We should educate our patients about the lack of benefit and potential side effects, and we should remember that ourselves.

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