Interventions available over the counter and advice for acute low back pain: systematic review and meta-analysis

J Pain. 2014 Jan;15(1):2-15. doi: 10.1016/j.jpain.2013.09.016. Epub 2013 Oct 14.


This systematic review evaluated evidence from randomized controlled trials investigating interventions available over the counter and advice that could be provided to people with acute low back pain. Searches were conducted on MEDLINE, Embase, Cochrane Database of Systematic Reviews, AMED, CENTRAL, and PsycINFO for eligible randomized controlled trials. The primary outcome measure was pain. Eligible controls included placebo, no treatment, or usual care. Two reviewers extracted data and rated study quality. A random effects model was used to pool trial effects with the overall strength of evidence described using the GRADE criteria. Thirteen randomized controlled trials (2,847 participants) evaluating advice, bed rest, simple analgesics (paracetamol, nonsteroidal anti-inflammatory drugs), heat application, and a topical rubefacient were included. There was low-quality evidence that bed rest is ineffective and very-low-quality evidence that advice is ineffective in the short, intermediate, and long terms. There was very-low-quality evidence that nonsteroidal anti-inflammatory drugs (ibuprofen and diclofenac "when required" dosing) provide an immediate analgesic effect (mean differences -10.9 [95% confidence interval = -17.6 to -4.2] and -11.3 [95% confidence interval = -17.8 to -4.9], respectively). There is very-low-quality evidence that heat wrap and a capsicum-based rubefacient provide an immediate analgesic effect (mean differences -13.5 [95% confidence interval = -21.3 to -5.7] and 17.5, P < .001, respectively), but there was no information on longer-term outcomes.

Perspective: There is limited evidence that nonsteroidal anti-inflammatory drugs, heat wrap, and rubefacients provide immediate pain relief for acute back pain and that bed rest and advice are both ineffective. Future research is needed to provide evidence to support rational use of over-the-counter remedies and advice for people with acute low back pain.

Keywords: Low back pain; advice; nonsteroidal anti-inflammatory drugs; over the counter; paracetamol.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Acute Disease
  • Behind-the-Counter Drugs / therapeutic use*
  • Humans
  • Low Back Pain / drug therapy*
  • Referral and Consultation*


  • Behind-the-Counter Drugs