You better sit down for this… (Updated)

A large study, published yesterday in the very fancy journal The Lancet, has found that Paracetamol is not effective for treating back pain.

Here’s a link to an interview with the studies lead researcher and excerpts from the transcript

Paracetamol no more effective than placebo at treating back pain: study

CHRIS UHLMANN: The most common pain reliever for back pain, paracetamol, doesn’t work any better than a placebo.

The shocking conclusion that the beneficial effects of such a widely-used drug might be all in the mind are drawn by a paper published this morning in the prestigious medical journal, The Lancet.

Dr Norman Swan of Radio National’s Health Report picked himself up off the floor to get to the story.

NORMAN SWAN: Eighty per cent of us will experience a bad back at some point in our lives and guidelines for doctors around the world advise GPs to tell patients not to lie down to their pain and to take paracetamol to relieve it, but when researchers from George Institute for Global Health in Sydney looked for good scientific evidence that paracetamol worked, they were troubled to find out there was none.

So they carried out a large three-pronged trial and 1,600 patients with acute new onset back pain. They all got the don’t lie down to it advice, but in terms of pain relief, one group received a placebo, another was told to take paracetamol as needed and a third received regular extended release paracetamol three times a day.

Professor Chris Maher was the study leader.

CHRIS MAHER: Surprisingly found that it didn’t really matter whether you gave people placebo as required, paracetamol or time contingent , that is regular paracetamol, there was no difference in any of the outcomes. It didn’t speed time to recovery; it didn’t improve their pain; it didn’t improve their disability.

NORMAN SWAN: Simply extraordinary!

CHRIS MAHER: Yeah, we were very surprised because by hypothesis was that there would be a difference between the people getting the regular paracetamol and placebo and I was expecting that, if you took paracetamol as required, so occasionally taking a tablet it wouldn’t work at all.

NORMAN SWAN: Does paracetamol work for anything? Is it a painkiller?

CHRIS MAHER: The jury’s out on that particular issue, so there is some evidence that it works for things such as dental procedures; it might work for fever, post-operative pain. We’ve looked at some of the trials for paracetamol for osteoarthritis, which is another common indication, and surprisingly when you go and have a very good look at them, we see the effects of paracetamol for osteoarthritis are very small.

NORMAN SWAN: So what about the more toxic forms of painkillers: the non-steroidals, the ibuprofens that can cause stomach ulcers and other problems with your blood pressure and so on. Is there any evidence that they’re actually pain killers?

CHRIS MAHER: These are very commonly prescribed medicines for back pain. If you go and look at the evidence, it’s really quite weak.

The evidence is certainly not robust for the common pain medicines that people are using for back pain.

NORMAN SWAN: So where do you go from here when I next pull my back?

CHRIS MAHER: Well, I think that the strong messages you can take from our trial is that people in the three groups all recovered remarkably quickly. Half the people had recovered by two weeks. And so what we’re thinking is that the interactions between the GP and the patient, the GP carefully guiding the person to resume normal activity; don’t put themselves to bed – maybe that’s the most important part of the therapy.” (Emphasis added)

 

The only surprise for me is that anyone was surprised! Why would anyone think that taking paracetamol would have any effect on time to recovery for low back pain?

It’s also interesting to note that the reporter interpreted these findings as suggesting that “the beneficial effects of such a widely-used drug might be all in the mind”. I think it would be more accurate to say simply that there were no beneficial effects. The authors say as much in the abstract – “We recorded no difference between treatment groups for time to recovery”

Here’s the final word from the online abstract:

Interpretation

Our findings suggest that regular or as-needed dosing with paracetamol does not affect recovery time compared with placebo in low-back pain, and question the universal endorsement of paracetamol in this patient group.

Funding

National Health and Medical Research Council of Australia and GlaxoSmithKline Australia.

Perhaps there’s another little surprise in the note on funding.

-Tim Cocks

www.noigroup.com

Update: There’s now a competition to win an ebook- see the comments below.

 

Get your think on and get up to date at a noigroup course, or immerse yourself in some brainy books with Explain Pain 2nd Ed and The Graded Motor Imagery Handbook

10 Responses to “You better sit down for this… (Updated)”

  1. davidboltononoi

    Maybe one take home nugget here is expressed in a phrase I use in response to such comments as:-
    I should sleep on a hard bed
    Never cross my legs as it’s bad for my back
    I have more back pain because I’m tall
    I have one leg shorter than the other that why my back hurts
    Etc. Etc. Etc.
    “Who says so”? ????????
    It would be interesting to gather similar claims here on this post if anyone is interested……!!!!!!!
    Tim might even offer a prize for the winner……what do you say Tim ?????
    DB
    On location

    Reply
    • timcocks0noi

      Alright DB on location, you’re on! (shakes fist as made to work on weekend).
      ebook of your choice (EP 2nd ed or The Graded Motor Imagery Handbook) to the best claim WITH the best response from the therapist/clinician…..
      I’ll have an impartial judge at noi HQ decide the winner Tuesday 29 July at 2:00pm (Australian Central Time)
      TC
      At home

      Reply
  2. Nigel Roff (@WillsmereHealth)

    Hi David I agree with your sentiment but wonder if the statement “who says so?” Is a bit too combatitive? In the the interests of a therapeutic outcome the last thing we want to do is start an argument with the patient. I had a patient in yesterday with some acute low back pain and off her own bat she brought up the paracetamol study that she had just read about in the paper describing its Ineffectiveness. In the next breath she says to me ” But it does work!”. Now these sorts of conversations with patients regarding a anything from drugs to posture ,exercise etc are not isolated incidents, I found I have them everyday. This leads me to a term I think it is called “Resistive Disconfirmation”, loosely translated it I think it means that even if you present someone with cast iron evidence that what they are saying is wrong or incorrect, they will tilt their head at you (literally or metaphorically ) and say “yeh,well” and continue along their line of belief. This reconceputalising is the hardest thing in patient interaction to deal with. Some people say, don’t bother with the patients who aren’t on the same page as you, but I feel they are the ones we need to all put our energies into, the greatest return will come shifting slowly the sandstone ideas. After 20 plus years, As far as reconceputalising goes, I have good,bad, and terrible days, and days where I think, why do I bother! But the quest continues. Ok, to a prize winning response, well, I don’t have one I think. Maybe my best response these days is none, I.e. Just listen, let them say what they think then we slowly workshop it thru the treatment, sometimes they end up reconceputalising themselves by the end by me just listening.

    Reply
  3. davidboltononoi

    Hi Nigel
    Yes maybe you are right but I’m old and grey with no time to waste and a long repertoire of short cuts so when on a “new date” I skip the flowers and romantic supper and get straight to the chalice, which can actually work for you………..;-)
    DB
    On Location

    Reply
  4. davidboltononoi

    With my patient who was convinced that crossing her legs was detrimental for her back she did chuckle when I said “Your husband is s a lucky man”
    DB
    On location

    Reply
  5. Efwef Gwerb

    Yo, live on location here.

    Claim: “My chiro says my leg is longer on this side and it’s caused my pelvis to become twisted. I usually see him but he is away this weekend and I was desperate. I have a friend who comes here”.

    Me: [after a very careful examination]. “Well the thing is, your leg is longer on this side and it’s caused your pelvis to become twisted”. : D

    Regarding the paracetamol thing, I had the same ‘shrug shoulder’ response. Maybe it’s the decline effect (the drug, not me).

    Reply
  6. Efwef Gwerb

    Check this out.

    Panadol® Tablets (12, 24, 50, 100)
    Panadol® Tablets with Optizorb® Technology (12, 24, 50, 100)
    Panadol Caplets® with Optizorb® formulation (12, 24, 48)
    Panadol® Mini Caps (12, 24, 48)
    Panadol® Gel Caps (24)
    Panadol® Rapid Handipak (10)
    Panadol® Rapid (24, 40)
    Panadol® Rapid Soluble (20)
    Panadol® EXTRA Caplets® (18, 36)
    Panadol® Osteo (96)
    Panadol® Suppositories (24)
    Panadol® Back + Neck Caplets (10,24)
    Panadol® Back + Neck Long-Lasting Caplets (18, 36)

    One drug, 13 “different” products. I hope the marketing team got a bonus for this effort.

    I hear they are releasing a new one next year: Panadol Optizorb technology (trademark), back but not neck (trademark), reasonably rapid but not as rapid as the handipak (trademark), only on Sundays (trademark pending) shove-it-up-your-arse suppository gel caplet (trademark pending).

    Reply
  7. Ariel Desjardins Charbonneau

    patient: My feet hurts so much today i’d like to cut if off
    Me: I have a rusty chainsaw in our archiving room if you want. But the thing is that you have more than 50% chance to still experience pain even if your feet is cut off. … and here starts my neuroscience education about pain

    Reply
  8. wesleykurszewski0noi

    While i don’t have a quick reserve/recall of funky reasons for pain, i can report some brilliant remedies, which might suggest that the absence of such was the reason for one’s pain.

    Lovely tale of multi-year, nearly intractable LBP resolved after a trip across the United States and insertion of a pin into the lower back of a pin cushion type doll with human dimensions.

    Equally lovely remedy for a six month pattern of neck pain was for another gentleman to have his cat cuddle around his neck and chest while he lazed in his favorite recliner.

    Awaiting for the research studies to support the claims, via finding from local Humane Societies and Sewing Clubs.

    I do recall a 30 something veteran presenting initially in a relatively unchecked, rambling fashion regarding his multiple stressors (diagnosis lower back and heel pain), to conclude near the end of the session (promoted almost exclusively by his own rambling) that “I’m starting to think it might all be in my head”. “Really? Tell me more”, i replied. He did alright in the end.

    Reply
  9. timcocks0noi

    And the winner is……

    Ariel – congratulations.

    Dominic, our newest noi recruit and an audio-visual genius, thought Ariel’s rusty chainsaw amputation offer that segued into the beginning of a phantom limb and pain science story was rather clever.

    Ariel, I’ll be in touch via email to discuss your ebook prize!

    Thanks to all who contributed comments.

    Tim

    Reply

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