The best treatment for acute lower back pain is a painkiller plus normal activity, a trial in Australia has shown.

Fancier treatments such as spinal manipulation, or the use of an anti-inflammatory drug, did nothing to speed recovery, say Mark Hancock, of the Back Pain Research Group at the University of Sydney, and colleagues.

The great majority of patients had recovered within two months, whatever the treatment.

So basic reassurance from a GP that all will be well, combined with advice to take paracetamol as a painkiller, keep active, and avoid bed rest, works just as well as referral to a physiotherapist, prescribing diclofenac, or both.

But the trial covered only acute lower back pain. Whether the same conclusions hold true for chronic pain, or for acute pain in other parts of the body, remains unknown.

The team found 240 patients with acute lower back pain who had gone to their GPs for treatment. All had been given first-line treatment: advice to keep active, plus paracetamol.

They were then randomly allocated to four groups of 60 each, who were given different treatments. One group was treated with diclofenac (a non-steroidal anti-inflammatory drug, or NSAID) and spinal manipulation by a physiotherapist; one to spinal manipulation plus a placebo drug; one to “false” spinal manipulation plus diclofenac, and one to false manipulation plus a placebo drug.

Whatever the treatment, patients recovered at the same rate. “Neither diclofenac nor spinal manipulative therapy gave clinically useful effects on the primary outcome of time to recovery,” the team concludes in The Lancet.

So the result is that neither of these treatments adds anything to the basic front-line treatment given by the GPs. While other NSAIDs were not tested, the team suspects the conclusions would apply to them as well.

“These results are important because both diclofenac and spinal manipulative therapy have potential risks and additional costs for patients,” the team concludes.

“If patients have high rates of recovery with baseline care and no clinically worthwhile benefit from the addition of diclofenac or spinal manipulative therapy, the GPs can manage patients confidently without exposing them to increased risks and costs.”

In a commentary in the medical journal The Lancet, Dr Bart Koes, of Erasmus University Medical Center in Rotterdam, says that the findings may have wider implications.

“The important message is that the management of acute low back pain in primary care (advice and prescription of paracetemol) is sufficient for most patients.”

Edzard Ernst, Professor of Complementary Medicine at Peninsula Medical School, Exeter, said: “The study seems to impressively confirm what has been known for some time, even some of the more enlightened guidelines include advice along those lines.”

Dr Stuart Derbyshire, senior lecturer in the School of Psychology and an expert in pain at the University of Birmingham, said: “For most people, providing simple care and advice should guide the patient through their acute phase of pain and allow them to return to normal life when that acute phase is over. It is reassuring that this appears to have happened in The Lancet study.”

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