Acute low back pain is one of the most common reasons patients present to the emergency department. Yet, when it comes to evidence-based management, our approaches often feel like “dealer’s choice.” We know NSAIDs are better than muscle relaxers and opioids, but what about topical options?
Enter the study by Khankel et al., recently published in Annals of Emergency Medicine. This randomized controlled trial (RCT) offers new insights into the effectiveness of topical NSAIDs, systemic NSAIDs, and combination therapy for acute, non-traumatic low back pain. Let’s break it down.
The Study at a Glance
This study investigated three arms of treatment for adults presenting with acute, undifferentiated low back pain severe enough to warrant an emergency visit:
- Oral Ibuprofen - 400 mg + placebo every six hours
- Topical Diclofenac Gel - 1%, 4g application + oral placebo pill every six hours
- Combination Therapy - Oral ibuprofen + topical diclofenac every six hours
The primary endpoint was an improvement in functional status at 48 hours, measured by the Roland-Morris Disability Questionnaire (RMDQ), a tool that assesses symptom burden and daily life impact.
Key Findings
After two days, all three groups had improvement compared to the baseline.
- Oral Ibuprofen provided the greatest improvement in functional outcomes, reducing the RMDQ score by 12 points on average.
- Topical Diclofenac reduced scores by 9 points, trailing slightly behind oral ibuprofen.
- The Combination Therapy offered no additional benefit over oral ibuprofen alone, with an average reduction of 10 points.
For most patients, oral ibuprofen remains the gold standard, but topical diclofenac provides a viable alternative, particularly for those with contraindications to systemic NSAIDs.
Interesting Takeaways for Clinicians
- Systemic NSAIDs Work Best
Oral ibuprofen at the analgesic ceiling dose of 400 mg was the most effective in reducing symptom burden. Higher doses won’t enhance pain relief but may increase side effects—so stick to this sweet spot.
- Topical NSAIDs Are a Good Plan B
Topical diclofenac is an excellent alternative for patients with GI intolerance, cardiovascular risks, or anticoagulation concerns. Its efficacy, while slightly less than oral ibuprofen, remains clinically significant and has fewer systemic side effects.
- Skip the Combo
Combining systemic and topical NSAIDs doesn’t provide a synergistic effect. If one route is already effective, there’s no need to add an alternative route.
- Set Expectations
Acute low back pain often improves significantly within 48 hours of appropriate treatment. However, most patients continue to require some form of analgesia for up to a week. Encourage patients to consider PT or, at a minimum, include stretching and strengthening exercises within a few days as part of their recovery plan.
Clinical Bottom Line
For emergency department patients with acute low back pain:
- Start with systemic NSAIDs like ibuprofen unless contraindicated.
- Consider topical NSAIDs as a safe and effective alternative for patients who can’t tolerate oral medications.
- Avoid combining the two, as the added benefit is negligible.
Most importantly, guide patients toward early mobilization and exercise as part of their recovery to address the underlying issue and prevent recurrence.
So, when your next patient asks for advice, you might just say: "Rub some gel on it… or pop a pill—either way, we’ll get you moving again."