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Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

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Abstract

Purpose

To evaluate the effectiveness of non-steroidal anti-inflammatory drugs (NSAIDs) for the management of neck pain and associated disorders (NAD), whiplash-associated disorders, and non-specific low back pain (LBP) with or without radiculopathy.

Methods

We systematically searched six databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible systematic reviews using the Scottish Intercollegiate Guidelines Network criteria. We included systematic reviews with a low risk of bias in our best evidence synthesis.

Results

We screened 706 citations and 14 systematic reviews were eligible for critical appraisal. Eight systematic reviews had a low risk of bias. For recent-onset NAD, evidence suggests that intramuscular NSAIDs lead to similar outcomes as combined manipulation and soft tissue therapy. For NAD (duration not specified), oral NSAIDs may be more effective than placebo. For recent-onset LBP, evidence suggests that: (1) oral NSAIDs lead to similar outcomes to placebo or a muscle relaxant; and (2) oral NSAIDs with bed rest lead to similar outcomes as placebo with bed rest. For persistent LBP, evidence suggests that: (1) oral NSAIDs are more effective than placebo; and (2) oral NSAIDs may be more effective than acetaminophen. For recent-onset LBP with radiculopathy, there is inconsistent evidence on the effectiveness of oral NSAIDs versus placebo. Finally, different oral NSAIDs lead to similar outcomes for neck and LBP with or without radiculopathy.

Conclusions

For NAD, oral NSAIDs may be more effective than placebo. Oral NSAIDs are more effective than placebo for persistent LBP, but not for recent-onset LBP. Different oral NSAIDs lead to similar outcomes for neck pain and LBP.

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Acknowledgments

The authors acknowledge the invaluable contributions to this review from: Angela Verven, J. David Cassidy, Douglas Gross, Gail Lindsay, John Stapleton, Leslie Verville, Margareta Nordin, Michel Lacerte, Mike Paulden, Murray Krahn, Patrick Loisel, and Roger Salhany. The authors also thank Trish Johns-Wilson at the University of Ontario Institute of Technology for her review of the search strategy. This study was funded by the Ontario Ministry of Finance and the Financial Services Commission of Ontario (RFP No.: OSS_00267175). The funding agency was not involved in the collection of data, data analysis, interpretation of data, or drafting of the manuscript. The research was undertaken, in part, thanks to funding from the Canada Research Chairs program to Dr. Pierre Côté, Canada Research Chair in Disability Prevention and Rehabilitation at the University of Ontario Institute of Technology.

Conflict of interest

Dr. Pierre Côté has received a grant from the Ontario Government, Ministry of Finance; a grant from Aviva Canada; and funding from the Canada Research Chairs program. Dr. Robert Brison and Dr. Silvano Mior have received an honorarium as a guideline expert panel member. For the remaining authors, no conflicts of interest were declared.

Author information

Authors and Affiliations

  1. UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada

    Jessica J. Wong, Pierre Côté, Sharanya Varatharajan, Thepikaa Varatharajan, Heather M. Shearer, Deborah Sutton, Kristi Randhawa, Hainan Yu, Danielle Southerst, Maja Stupar & Anne Taylor-Vaisey

  2. Undergraduate Education, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada

    Jessica J. Wong

  3. Division of Graduate Studies, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada

    Jessica J. Wong

  4. Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, ON, L1H 7L7, Canada

    Pierre Côté, Rachel Goldgrub & Silvano Mior

  5. Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal, N-414, Roger-Gaudry Building, 2900, Boulevard Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada

    Arthur Ameis

  6. Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada

    Sharanya Varatharajan, Heather M. Shearer, Deborah Sutton, Kristi Randhawa, Hainan Yu & Silvano Mior

  7. Graduate Studies in Masters of Public Health, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK, S7N 5E5, Canada

    Thepikaa Varatharajan

  8. Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada

    Robert J. Brison

  9. Department of Emergency Medicine, School of Medicine, Queen’s University, Kingston, ON, Canada

    Robert J. Brison

  10. Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex, 60 Murray Street, 2nd Floor (Main), Toronto, ON, M5T 3L9, Canada

    Danielle Southerst

  11. Injury Prevention Centre, University of Alberta, 4075 RTF, 8308 114 Street, Edmonton, T6G 2E1, AB, Canada

    Linda J. Carroll

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  1. Jessica J. Wong
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  2. Pierre Côté
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  3. Arthur Ameis
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  4. Sharanya Varatharajan
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  5. Thepikaa Varatharajan
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  6. Heather M. Shearer
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  7. Robert J. Brison
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  8. Deborah Sutton
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  16. Anne Taylor-Vaisey
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Corresponding author

Correspondence to Jessica J. Wong.

Additional information

Systematic Review Registration Number: CRD42014009782.

Appendix I: MEDLINE (Ovid Technologies Inc.) search strategy for whiplash-associated disorders, neck pain and associated disorders, non-specific low back pain, and non-steroidal anti-inflammatory drugs (NSAIDs)

Appendix I: MEDLINE (Ovid Technologies Inc.) search strategy for whiplash-associated disorders, neck pain and associated disorders, non-specific low back pain, and non-steroidal anti-inflammatory drugs (NSAIDs)

  1. 1.

    Whiplash Injuries/

  2. 2.

    Neck Injuries/

  3. 3.

    Neck Pain/

  4. 4.

    Neck Muscles/in [Injuries]

  5. 5.

    exp Cervical Vertebrae/in [Injuries]

  6. 6.

    Radiculopathy/

  7. 7.

    exp Brachial Plexus Neuropathies/

  8. 8.

    Torticollis/

  9. 9.

    whiplash.ab,ti.

  10. 10.

    “neck injur*”.ab,ti.

  11. 11.

    “neck pain*”.ab,ti.

  12. 12.

    “cervical pain*”.ab,ti.

  13. 13.

    “neck ache*”.ab,ti.

  14. 14.

    “neckache*”.ab,ti.

  15. 15.

    “cervicalgia*”.ab,ti.

  16. 16.

    “cervicodynia*”.ab,ti.

  17. 17.

    “radiculopath*”.ab,ti.

  18. 18.

    “brachial plexus neuropath*”.ab,ti.

  19. 19.

    torticollis.ab,ti.

  20. 20.

    or/1-19

  21. 21.

    exp Back/

  22. 22.

    exp Back Injuries/

  23. 23.

    exp Back Pain/

  24. 24.

    Coccyx/in [Injuries]

  25. 25.

    Intervertebral Disc Degeneration/

  26. 26.

    Intervertebral Disc Displacement/

  27. 27.

    Lumbar Vertebrae/in [Injuries]

  28. 28.

    exp Lumbosacral Plexus/

  29. 29.

    Lumbosacral Region/in [Injuries]

  30. 30.

    Osteoarthritis, Spine/

  31. 31.

    Piriformis Muscle Syndrome/

  32. 32.

    Polyradiculopathy/

  33. 33.

    Sacrococcygeal Region/

  34. 34.

    Sacroiliac Joint/

  35. 35.

    Sacrum/

  36. 36.

    Sciatica/

  37. 37.

    Spinal Diseases/

  38. 38.

    Spinal Stenosis/

  39. 39.

    (avulsed lumbar adj3 (disc* or disk*)).ab,ti.

  40. 40.

    (back adj3 (ache* or injur* or pain*)).ab,ti.

  41. 41.

    (backache* adj3 (injur* or pain*)).ab,ti.

  42. 42.

    (back pain or back-pain).ab,ti.

  43. 43.

    coccydynia.ab,ti.

  44. 44.

    coccyx.ab,ti.

  45. 45.

    dorsalgia.ab,ti.

  46. 46.

    (lumbar disc* adj3 (extruded or degenerat* or herniat* or prolapse* or sequestered or slipped)).ab,ti.

  47. 47.

    (lumbar disk* adj3 (extruded or degenerat* or herniat* or prolapse* or sequestered or slipped)).ab,ti.

  48. 48.

    “low* back pain”.ab,ti.

  49. 49.

    “low*-back-pain*”.ab,ti.

  50. 50.

    (lumbar adj3 (pain or facet or nerve root* or osteoarthritis or radicul* or spinal stenosis or spondylo* or zygapophys*)).ab,ti.

  51. 51.

    “lumbarsacr*”.ab,ti.

  52. 52.

    lumboischialgia.ab,ti.

  53. 53.

    “lumbosacr*”.ab,ti.

  54. 54.

    “Piriformis syndrome*”.ab,ti.

  55. 55.

    radiculalgia.ab,ti.

  56. 56.

    (sacral adj2 pain*).ab,ti.

  57. 57.

    (sacrococcygeal adj2 pain*).ab,ti.

  58. 58.

    (sacroiliac or sacro-iliac).ab,ti.

  59. 59.

    “sciatic*”.ab,ti.

  60. 60.

    (SI adj joint).ab,ti.

  61. 61.

    (spinal adj stenos?s).ab,ti.

  62. 62.

    spondylosis.ab,ti.

  63. 63.

    “tailbone adj3 pain*”.ab,ti.

  64. 64.

    “vertebrogenic adj3 pain*”.ab,ti.

  65. 65.

    or/21-64

  66. 66.

    20 or 65

  67. 67.

    exp Anti-Inflammatory Agents, Non-Steroidal/

  68. 68.

    alclofenac.ab,hw,ti,nm.

  69. 69.

    Aspirin.ab,hw,ti,nm.

  70. 70.

    Cyclooxygenase 2.ab,hw,ti,nm.

  71. 71.

    benoxaprofen.ab,hw,ti,nm.

  72. 72.

    Benzydamine.ab,hw,ti,nm.

  73. 73.

    Bufexamac.ab,hw,ti,nm.

  74. 74.

    celecoxib.ab,hw,ti,nm.

  75. 75.

    dexibuprofen.ab,hw,ti,nm.

  76. 76.

    dexketoprofen trometamol.ab,hw,ti,nm.

  77. 77.

    Diclofenac.ab,hw,ti,nm.

  78. 78.

    Dipyrone.ab,hw,ti,nm.

  79. 79.

    Diflunisal.ab,hw,ti,nm.

  80. 80.

    droxicam.ab,hw,ti,nm.

  81. 81.

    Etodolac.ab,hw,ti,nm.

  82. 82.

    etofenamate.ab,hw,ti,nm.

  83. 83.

    etoricoxib.ab,hw,ti,nm.

  84. 84.

    Fenoprofen.ab,hw,ti,nm.

  85. 85.

    firocoxib.ab,hw,ti,nm.

  86. 86.

    Flufenamic Acid.ab,hw,ti,nm.

  87. 87.

    Flurbiprofen.ab,hw,ti,nm.

  88. 88.

    Ibuprofen.ab,hw,ti,nm.

  89. 89.

    Indomethacin.ab,hw,ti,nm.

  90. 90.

    isoxicam.ab,hw,ti,nm.

  91. 91.

    Ketoprofen.ab,hw,ti,nm.

  92. 92.

    Ketorola.ab,hw,ti,nm.

  93. 93.

    loxoprofen.ab,hw,ti,nm.

  94. 94.

    lumiracoxib.ab,hw,ti,nm.

  95. 95.

    lysine clonixinate.ab,hw,ti,nm.

  96. 96.

    Magnesium Salicylate.ab,hw,ti,nm.

  97. 97.

    Meclofenamic Acid.ab,hw,ti,nm.

  98. 98.

    Mefenamic Acid.ab,hw,ti,nm.

  99. 99.

    meloxicam.ab,hw,ti,nm.

  100. 100.

    morniflumate.ab,hw,ti,nm.

  101. 101.

    Naproxen.ab,hw,ti,nm.

  102. 102.

    Niflumic Acid.ab,hw,ti,nm.

  103. 103.

    Oxyphenbutazone.ab,hw,ti,nm.

  104. 104.

    piketoprofen.ab,hw,ti,nm.

  105. 105.

    Piroxicam.ab,hw,ti,nm.

  106. 106.

    salicylsalicylic acid.ab,hw,ti,nm.

  107. 107.

    Sulindac.ab,hw,ti,nm.

  108. 108.

    tenoxicam.ab,hw,ti,nm.

  109. 109.

    Tolmetin.ab,hw,ti,nm.

  110. 110.

    valdecoxib.ab,hw,ti,nm.

  111. 111.

    or/67-110

  112. 112.

    Actron.ti,ab.

  113. 113.

    Acular.ti,ab.

  114. 114.

    Advil.ti,ab.

  115. 115.

    Afrolate.ti,ab.

  116. 116.

    Aleve.ti,ab.

  117. 117.

    Algesalona.ti,ab.

  118. 118.

    Amigesic.ti,ab.

  119. 119.

    Anacin.ti,ab.

  120. 120.

    Anaflex 750.ti,ab.

  121. 121.

    Anaprox.ti,ab.

  122. 122.

    Ansaid.ti,ab.

  123. 123.

    Arthitab.ti,ab.

  124. 124.

    Arthropam.ti,ab.

  125. 125.

    Arthrotec.ti,ab.

  126. 126.

    Ascriptin.ti,ab.

  127. 127.

    Bayer.ti,ab.

  128. 128.

    Bayro.ti,ab.

  129. 129.

    Bextra.ti,ab.

  130. 130.

    Bufferin.ti,ab.

  131. 131.

    Cambia.ti,ab.

  132. 132.

    Cataflam.ti,ab.

  133. 133.

    celebrex.ti,ab.

  134. 134.

    Clinoril.ti,ab.

  135. 135.

    Cuprofen.ti,ab.

  136. 136.

    Daypro.ti,ab.

  137. 137.

    Diflamil.ti,ab.

  138. 138.

    Dignodolin.ti,ab.

  139. 139.

    Disalcid.ti,ab.

  140. 140.

    Doan’s Pills.ti,ab.

  141. 141.

    Dolinac.ti,ab.

  142. 142.

    Dolobid.ti,ab.

  143. 143.

    Duexis.ti,ab.

  144. 144.

    Ecotrin.ti,ab.

  145. 145.

    Feldene.ti,ab.

  146. 146.

    Fenbid.ti,ab.

  147. 147.

    Fenomel.ti,ab.

  148. 148.

    Fentiazac.ti,ab.

  149. 149.

    Flector.ti,ab.

  150. 150.

    Flexidol.ti,ab.

  151. 151.

    Flexium.ti,ab.

  152. 152.

    Flogoprofen.ti,ab.

  153. 153.

    Flurwood.ti,ab.

  154. 154.

    Froben.ti,ab.

  155. 155.

    Hifenac.ti,ab.

  156. 156.

    Ibuprofen.ti,ab.

  157. 157.

    Indocin.ti,ab.

  158. 158.

    Indomethegan.ti,ab.

  159. 159.

    Ketofen.ti,ab.

  160. 160.

    Lodine.ti,ab.

  161. 161.

    Magan.ti,ab.

  162. 162.

    Marthritic.ti,ab.

  163. 163.

    Meclomen.ti,ab.

  164. 164.

    Mobic.ti,ab.

  165. 165.

    Mobidin.ti,ab.

  166. 166.

    Mobogesic.ti,ab.

  167. 167.

    Mono-Gesic.ti,ab.

  168. 168.

    Motrin.ti,ab.

  169. 169.

    Nalfon.ti,ab.

  170. 170.

    Naprelan.ti,ab.

  171. 171.

    Naprosyn.ti,ab.

  172. 172.

    Niflatol.ti,ab.

  173. 173.

    Niflugel.ti,ab.

  174. 174.

    Nifluril.ti,ab.

  175. 175.

    Nixyn.ti,ab.

  176. 176.

    Nuprin.ti,ab.

  177. 177.

    Oftalar.ti,ab.

  178. 178.

    Orudis.ti,ab.

  179. 179.

    Oruvail.ti,ab.

  180. 180.

    Paraderm.ti,ab.

  181. 181.

    Parfenac.ti,ab.

  182. 182.

    Pennsaid.ti,ab.

  183. 183.

    Ponstel.ti,ab.

  184. 184.

    Pranox.ti,ab.

  185. 185.

    Relafen.ti,ab.

  186. 186.

    Salflex.ti,ab.

  187. 187.

    Salsitab.ti,ab.

  188. 188.

    Sastridex.ti,ab.

  189. 189.

    Solaraze.ti,ab.

  190. 190.

    Solpaflex.ti,ab.

  191. 191.

    Sprix.ti,ab.

  192. 192.

    Suxibuzone.ti,ab.

  193. 193.

    Tiloket.ti,ab.

  194. 194.

    Tolectin.ti,ab.

  195. 195.

    Toradol.ti,ab.

  196. 196.

    Transact Lat.ti,ab.

  197. 197.

    Traumalix.ti,ab.

  198. 198.

    Traumon.ti,ab.

  199. 199.

    Traxam.ti,ab.

  200. 200.

    Trilisate.ti,ab.

  201. 201.

    Triparsean.ti,ab.

  202. 202.

    Triscosal.ti,ab.

  203. 203.

    Vimovo.ti,ab.

  204. 204.

    Vioxx.ti,ab.

  205. 205.

    voltaren*.ti,ab.

  206. 206.

    Voltarol.ti,ab.

  207. 207.

    or/112-206

  208. 208.

    111 or 207

  209. 209.

    acetylsalicyl*.ti,ab.

  210. 210.

    COX 1.ti,ab.

  211. 211.

    COX 2.ti,ab.

  212. 212.

    COX I.ti,ab.

  213. 213.

    COX II.ti,ab.

  214. 214.

    COX-1.ti,ab.

  215. 215.

    COX-2.ti,ab.

  216. 216.

    COX-I.ti,ab.

  217. 217.

    COX-II.ti,ab.

  218. 218.

    cyclooxygenase.ti,ab.

  219. 219.

    cyclo-oxygenase.ti,ab.

  220. 220.

    non-steroidal anti-inflammatory agent*.ti,ab.

  221. 221.

    nonsteroidal anti-inflammatory agent*.ti,ab.

  222. 222.

    NSAIA*.ti,ab.

  223. 223.

    NSAID*.ti,ab.

  224. 224.

    NSAIM*.ti,ab.

  225. 225.

    salicylate*.ti,ab.

  226. 226.

    or/209-225

  227. 227.

    208 or 226

  228. 228.

    66 and 227

  229. 229.

    Meta-Analysis as Topic/

  230. 230.

    Meta-Analysis.pt.

  231. 231.

    (meta adj analy*).ti,ab.

  232. 232.

    metaanaly*.ti,ab.

  233. 233.

    (systematic adj3 (review* or overview*)).ti,ab.

  234. 234.

    (methodologic* adj3 (review* or overview*)).ti,ab.

  235. 235.

    (integrative adj3 (review* or overview*)).ti,ab.

  236. 236.

    (collaborative adj3 (review* or overview*)).ti,ab.

  237. 237.

    exp Review Literature as Topic/

  238. 238.

    medline.ab.

  239. 239.

    pubmed.ab.

  240. 240.

    cochrane.ab.

  241. 241.

    embase.ab.

  242. 242.

    (psychlit or psyclit).ab.

  243. 243.

    (psychinfo or psycinfo).ab.

  244. 244.

    (cinahl or cinhal).ab.

  245. 245.

    science citation index.ab.

  246. 246.

    (reference adj list*).ab.

  247. 247.

    bibliograph*.ab.

  248. 248.

    (hand-search* or handsearch).ab.

  249. 249.

    manual search*.ab.

  250. 250.

    or/229-249

  251. 251.

    Review/

  252. 252.

    (selection adj3 criteria).ab.

  253. 253.

    (data adj3 (extraction or synthes*)).ab.

  254. 254.

    251 and (252 or 253)

  255. 255.

    250 or 254

  256. 256.

    228 and 255

  257. 257.

    limit 256 to (english language and humans and yr = “2000 -Current”)

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Wong, J.J., Côté, P., Ameis, A. et al. Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J 25, 34–61 (2016). https://doi.org/10.1007/s00586-015-3891-4

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