Recall Bias: Many of the inclusion/exclusion criteria and RMDQ were susceptible to recall bias, an error that can occur when participants are asked to remember events or experiences for a study.

Patient Population: Patients were recruited from an urban health care system in a socioeconomically depressed population. Socioeconomic factors may be associated with back pain outcomes, and these results may not necessarily apply to other patient populations.

Unbalanced Groups: Patients in the diazepam arm were more likely to be unemployed. This is a known prognostic factor in recovery in back pain patients.

Blinding: Patients in the benzodiazepine group may have been unblinded. While the authors reported no difference in those feeling dizzy or tired “a lot,” they did not report how many participants felt these side effects “a little.” However, you would expect any lack of blinding to have favored the diazepam group.

Bottom Line

Diazepam should not be routinely added to a NSAID for outpatient management of acute, nontraumatic low back pain patients presenting to the emergency department.

Case Resolution

The man is encouraged to use his naproxen if he feels it provides some benefit, stay active, follow up with his primary care physician, and return to the emergency department if any red flags develop. He also is reassured that symptoms may persist for weeks to months.

Thank you to Anand Swaminathan, MD, MPD, from Core EM and EM:RAP for his help with this review. Dr. Swaminathan is an assistant professor of emergency medicine in the department of emergency medicine at NYU/Bellevue Hospital in New York City.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References

1. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. Lancet. 2014;384(9954):1586-1596.
2. Friedman BW, Dym AA, Davitt M, et al. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA. 2015;314(15):1572-1580.
3. Cantrill SV, Brown MD, Carlisle RJ, et al. Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med. 2012;60(4):499–525.
4. Itz CJ, Geurts JW, van Kleef M, et al. Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care. Eur J Pain. 2013;17(1):5-15.
5. Donelson R, McIntosh G, Hall H. Is it time to rethink the typical course of low back pain? PM R. 2012;4(6):394-401;quiz 400.
6. da C Menezes Costa LC, Maher CG, Hancock MJ, et al. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ. 2012;184(11):E613–E624.