Is Paracetamol Suitable for Back pain?

Back pain and osteoarthritis combined, account for around 15% of all GP consultations and management of these patients, which has long been a challenge to the NHS, will not be helped by emerging evidence questioning the effectiveness and the safety of paracetamol!

Paracetamol, is cheap, possibly too cheap, readily available, and found in most homes around the world. We rely on it in for just about everything, but things may be about to change! Last year, a systematic review by Machado and colleagues cast doubts on both the effectiveness and the safety of paracetamol.

“paracetamol has only a very small effect in patients with hip or knee osteoarthritis”

Machado and colleagues, amalgamated evidence from thirteen randomised controlled trials and found “high quality” evidence that paracetamol has only a very small effect in patients with hip or knee osteoarthritis. They claim the small effects, less than 4 points on a 0–100 point scale, are unlikely to be significant for most patients. In addition, they also found “High quality” evidence that paracetamol is ineffective for back pain.

The effectiveness, or more correctly the ineffectiveness, of paracetamol use for back pain and osteoarthritis, was arguably not as an important a finding as the discovery that patients taking paracetamol were nearly four times more likely to have abnormal results on liver function tests.

To be fair, some of these findings are not entirely unexpected. Recent draft guidelines from the National Institute for Health and Care Excellence (NICE) on the management of osteoarthritis, advised against paracetamol being routinely offered to patients due to (a) it not being effective and (b) it potentially being associated with significant side effects when used at high doses for prolonged periods. This brave, but controversial decision was later reversed in the full issued guidelines following concerns that the change may lead to a dramatic increase in the prescription of other, potentially more harmful, medications such as Ibuprofen, or other non-steroidal anti-inflammatory drugs (NSAID’s).

“NICE guidelines recommend manual therapy

as an adjunct to exercise”

These recent findings highlight the importance of promoting non-pharmacological options. Topical NSAID’s for example, such as ibuprofen gel or cream, are a safer alternative to oral NSAID’s with fewer side effects, and have been shown to be equally effective in helping with osteoarthritis of the knee.

So where does osteopathy fit into all of this? Well, the recently updated NICE guidelines recommend manual therapy as an adjunct to exercise. I fully support this recommendation. Anyone who has been to my practice will hopefully have left with the impression that whilst the treatment will go a long way to reducing the current level of pain, simple lifestyle modifications, including exercise, are generally required to prevent the condition from returning. You simply cannot continue to do the same things day in day out and expect the outcome to be any different.

"Exercise is the best medicine, so take it daily"

There’s no doubting the effectiveness of exercise for osteoarthritis and back pain, but unfortunately, adherence to exercise is known to be poor. There are many reasons for this. In my experience, patients are often given exercises that are totally unsuitable for their age and/or physique or they are given too many exercises. Keep it simple and exercise is a very potent alternative to medication in the fight against arthritis and back pain; in fact, pain in general.

In light of these recent revelations would I still take paracetamol? Probably, if I had a cold or a headache, but for back pain or arthritis, definitely not. Exercise is the best medicine, so take it daily :-)

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