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Systematic Review

Effect of Methocarbamol on acute low back pain: A systematic review

[version 1; peer review: 2 not approved]
PUBLISHED 07 Oct 2024
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Abstract

Introduction

Pharamcological treatment for acute low back pain (ALBP) typically involves opioid drugs, and non-steroidal anti-inflammatory drugs (NSAIDs). Methocarbamol is utilized primarily for managing muscle spasms and pain. This systematic review aims to provide an updated synthesis of published literature on the effects of Methocarbamol on pain outcomes in ALBP.

Methods

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Original articles published until December 2023 were sourced from PubMed, Embase, and the Cochrane Library. Articles focusing on the impact of Methocarbamol on pain outcomes in ALBP patients were included.

Results

Three studies met the inclusion criteria, published between 2018 and 2023. The total study population comprised 405 ALBP patients, with 163 receiving Methocarbamol. Compared to patients not receiving Methocarbamol, those in the Methocarbamol group showed pain improvement at one week. However, at 30 and 60 minutes after intravenous administration, Methocarbamol was less effective than Diazepam. The primary reported adverse event was nausea.

Conclusion

When administered in combination with Indomethacin or Naproxen, Methocarbamol shows potential for improving pain outcomes at one week in ALBP patients. However, its efficacy appears inferior to Diazepam in the short-term management of pain

Keywords

Methocarbamol, Back pain, Acute

Introduction

Acute low back pain (ALBP) is defined as acute pain located below the costal margin and above the inferior gluteal folds.1 It can arise from a variety of causes and affects individuals of all ages.1 The intensity of ALBP can range from mild to severe, potentially leading to functional limitations such as difficulty walking and impaired daily activities.2 Consequently, ALBP imposes a significant burden on the healthcare system.2 In 2017, it accounted for 65 million years lived with disability in low- and middle-income countries.3 Additionally, ALBP is a common reason for visits to emergency departments (EDs).4 In the United States, it accounts for 2.4% of ED visits, totaling approximately 2.4 million visits annually.5

Regarding treatment modalities, ALBP is typically managed with non-steroidal anti-inflammatory drugs (NSAIDs), level 1 analgesics, and opioids, alongside physical therapy, which alleviates pain in most cases.6 However, despite adequate treatment with NSAIDs, half of the patients continue to experience pain after discharge from the ED. Additionally, methocarbamol, a central muscle relaxant, has been reported to have a beneficial effect on ALBP.7 Although its mechanism of action is not completely understood, it is believed to act through the central nervous system rather than directly on skeletal muscles.8 In the literature, there are still disagreements regarding the prescription of methocarbamol, primarily due to the lack of clear consensus on its appropriateness.

To provide a more comprehensive assessment, we conducted this systematic review to present the most up-to-date published literature on the effectiveness of methocarbamol in treating ALBP.

Methods

This systematic review adhered to the preferred reporting items for systematic review and metanalysis (PRISMA) guidelines.9 The data analyzed were sourced from published studiesand no ethical approval or written informed consent was necessary for this research.

Search strategy

Literature searches were performed in MEDLINE, EMBASE and Cochrane library from inception to December 2023. For PubMed, The searches used a combination of the MeSH (Medical Subject Headings) terms “Acute low back pain”, “methocarbamol” and “randomised controlled trial” or their synonyms. The inclusion criteria of this review was detailed in Table 1. Citation tracking was performed from included full-text articles and previous relevant systematic reviews. We included papers written in English language. In the Embase and Cochrane Library, the specified terms were searched within the article title, abstract, or keywords.

Table 1. The inclusion criteria of the review: Effect of Methocarbamol on acute low back pain.

Synonyms of acute low back painSynonyms of Methocarbamol
“Acute low back pain” [MESH] OR “Low back pain” [MESH]AND
“Methocarbamol”[Mesh]

Selection criteria

We included for the present paper 1) Randomized controlled trials including patients with ALBP and treated with Methocarbamol 2) Studies that compared Methocarbamol to another treatment or placebo in the management of ALBP 3) We did not restrict to any specific symptom severity or duration compared to groups with other medical treatments.

Data extraction and quality assessment

Publications that did not align in compliance with the purpose of this systematic review as well as those that were not original research including (metaanalysis, reviews, editorials, qualitative papers, case reports, comments, and letters to editors) were excluded. Additional articles were manually identifieng by reviewing the references of selected articles. In cases of studies had overlapping data, the most comprehensive one was chosen. After a through examination of titles and abstracts, articles not meeting the inclusion criteria were excluded. Data extraction and quality assessment Extracted data from each study was conducted independently by both investigators (YM and BW) then compared, discussed and finally any disagreements were resolved.

The extracted data encompassed the key methodological characteristics of the 3 studies: (year of publication, country, study design, number of included subjects, mean age of participants, inclusion and exclusion criteria and follow-up duration). Our primary outcome was the evaluation of the effect of Methocarbamol on relieving pain in patients with ALBP.

Furthermore, we identified potential biases of the RCTs using the revised Cochrane collaboration’s tool for assessing risk of bias (RoB2).10 Only studies that met high quality belonged to our final selection.

Results

For this update, we identified 104 papers through the database. After removing duplicates, we screened 4 titles and abstracts. We excluded a German language paper. In total, we finally included 3 papers for analysis. The flow chart of this systematic review is summarized in the extended data 1 (Refer extended data).

Characteristics of the studies

The main characteristics of the three studies included in this systematic review are summarized in extended data 2. These three RCTs were published in 2018, 2021, and 2023.1113 The studies were conducted in United States (n=1)11 and Iran (n=2).12,13 Inclusion criteria for these studies were adult patients aged 18 years or older with ALBP. Exclusion criteria included non-traumatic ALBP for all studies46 and the presence of radicular pain in the study by Benjamin W. et al.

Characteristics of the patients

Overall, 405 patients were included in the three studies, with sample sizes ranging from 6412 to 240.11 The mean age, when reported, was 41.4 years, although age extremes were not specified. Baseline characteristics were comparable between the groups. The control groups received either Orphenadrine or placebo,11 Indomethacin,12 or Diazepam.13 Methocarbamol was administered to 163 patients [32-81], in combination with Naproxen,11 Indomethacin,12 or morphine.13 The administration of methocarbamol was oral in two studies, with dosages ranging from 250 mg three times daily to 500 mg three times daily,11,12 and intravenous in one study, with a dosage of 100 mg in 10 ml IV over 3 minutes.13

The effect of Methocarbamol on pain and function disability

The effectiveness of Methocarbamol was evaluated at 30 and 60 minutes post-administration,13 at one week,11,12 and after three months.11 Pain was assessed with the Numeric Rating Scale (NRS),13 the Visual Analogue Scale (VAS),12 the Back Pain Function Scale (BPFS),12 and the ordinal pain scale.11 Only Friedman’s study evaluated functional impairment post-intervention using the RMDQ.11 At one week post-intervention, patients in the Methocarbamol + Indomethacin group experienced significantly greater reductions in VAS scores and improvements in BPFS compared to the Indomethacin alone group (VAS: 3.66 ± 3.17 vs. 1.84 ± 1.53; P < 0.001; BPFS: 19.44 ± 8.66 vs. 4.75 ± 4.35; p < 0.001).12 Similarly, the mean RMDQ score improved by 8.1 (95% CI: 6.1, 10.1) in the Methocarbamol group compared to the Orphenadrine and placebo groups, though this did not surpass the clinical significance threshold.11 No differences were observed in pain or functional outcomes at three months among the groups. In the study by Sharifi and al., NRS scores improved at 60 minutes compared to baseline in both groups, with a slightly greater reduction in pain in the Diazepam group compared to the Methocarbamol (mean difference: −6.1, 95% CI: −6.5 to −5.7 vs. −5.2, 95% CI: −5.7 to −4.7, respectively; p < 0.001).13 The distribution of various pain score measures is represented in Table 2.

Table 2. The distribution of pain scores and function scores.

BaselineAt 30 minAt 60 minAt 1 weekAt 3M
Friedman et al. (2018)RMDQ N+O/N+M/N+placebo---8.1 (6.1, 10.1)/9.4 (95%CI: 7.4, 11.5)/10.9 (95%CI: 8.9, 12.9)1.8 (95%CI: −0.7, 4.2)/1.1 (95%CI: -1.3,3.5) /0.7 (95%CI: -2.0, 3,3)
Samsamshariate et al. (2021)Pain score (M+I/I) Mean (SD)7.5±1.76/6.75±1.79--3.84±2.19/4.9±2.13**_
BPFS score (M+I/I)29.37±13.29/34.50±8.69__46.81±10.48/39.25±8.37**_
Sharifi et al. (2023)NRS (M/D) mean (SD) (2023)8.8(1.3)/8.6(1.3)4.7(2.4)/4.1(2.2)*3.6(2.6)/2.4(1.8)*8.8(1.3)/8.6(1.3)_

* P < 0.05.

** P < 0.001.

Factors associated with acute low back pain (ALBP) were assessed in two studies.12,13 In the study by Sharifi et al., baseline pain scores were comparabke between men and women measauring 8.8 (1.2) vs. 8.6 (1.4) (95% CI for the difference: -0.3 to 0.8, p = 0.326).13 In contrast, Shiva et al. found that male patients in the Methocarbamol + Indomethacin group had a significantly greater mean increase in back pain functional status (BPFS) compared to those in the Indomethacin alone group following the intervention (49.87 ± 10.82 vs. 39.67 ± 8.89; p < 0.05).12

Adverse events in the groups

Adverse events were evaluated in two studies.11,13 No serious or unexpected adverse events were reported. In the Methocarbamol group, side effects included central nervous system (CNS) adverse effects such as drowsiness,11,13 somnolence,13 drowsiness,11 stomach irritation11 and dizziness. However, side effects were comparable between the groups11,13 and were reported by 17% (95%CI: 10, 28%) of placebo patients, 9%(95%CI:4, 19%) of orphenadrine patients, and 19%(95%CI: 11, 29%) of methocarbamol patients. More importantly, Diazepam was significantly associated with CNS adverse effects compared to Methocarbamol.

Discussion

We conducted a systematic review of recent literature focusing on the impact of Methocarbamol on ALBP, encompassing three articles. The key findings derived from this review are as follows: 1) Methocarbamol demonstrated an overall beneficial effect in treating ALBP, and 2) This positive effect did not correlate with an increase in adverse events.

The management of ALBP in the emergency department varies and is specific to each unit, primarily due to conflicting evidence regarding the efficacy of analgesics.14 While acetaminophen, NSAIDs, and muscle relaxants have shown modest analgesic effects in short-term trials,15 they continue to be widely used in daily practice. However, the limited alternatives available have led some to resort to other medications such as opioids and diazepam.16 The latter was more effective than placebo in improving ALBP. However, opioids are associated with several adverse events mainly sedation and constipation, and are not recommended as a long-term treatment.

Similarly, muscle relaxants are also considered a treatment option for reducing muscle spasms. Several guidelines recommend the use of Methocarbamol in the management of ALBP in general, with varying effects. Two systematic reviews yielded robust results, indicating the effectiveness of muscle relaxant therapy in treating simple ALBP, with maximum benefit observed within the first 2 weeks.17,18 Similarly, muscle relaxants are also a treatment option through reducing muscle spasms. Several guidelines recommend the use of Methocarbamol in the management of LBP in general with variable effect. Two systematicreviews provided robust results indicating the effectiveness of muscle relaxant therapy in treating simple acute low back pain with a maximum benefit in the first 2 weeks.17,18

In this review, the effect was observed at one week, although 30% still had LBP at 3 months.2 Ideally, this subgroup of patients should be targeted for close follow-up to prevent the transition from acute to chronic pain.4 Similarly, current evidence suggests that Methocarbamol may be more beneficial when used alongside other therapeutic modalities, particularly analgesics and NSAIDs.18 This was corroborated in our review, which found strong evidence that combining Methocarbamol with NSAIDs enhances recovery. Furthermore, our review highlighted the adverse events associated with Methocarbamol, particularly those affecting the central nervous system, similar to those seen with Benzodiazepine treatments.18 As a result, while Methocarbamol shows promise as an alternative for reducing ALBP, caution is advised in its use.

To the best of the authors’ knowledge, this is first systematic review evaluating the effect of Methocarbamol on ALB. However, there are some limitations to consider. Firstly, the number of investigated studies was limited. Nonetheless, this review incorporated RCTs with sufficient sample sizes to yield statistically significant results and the quality of the studies was rated as good according to the Cochrane tool risk assessment bias. On the other hand, Methocarbamol was combined with NSAIDs in two studies,4,5 which may hinder the real effect of the studied molecule. Future trials should adress this issues by including larger sample sizes and control groups to better understand the specific implication of each subset ultimately leading to a more comprhensive approach.

Conclusion

Current evidence suggests that Methocarbamol may improve pain in ALBP patients after one week of use. However, more rigorous prospective controlled studies with extended follow-up are necessary to.

Finding suggests that Methocarbamol may improved pain in patients with acute low back pain (ALBP) after one week of use. Moreover, it is suggested that additional and rigourous prospective controlled research should be undertaken to further explore these treatments with longer follow-up periods.

Author contribution

  • - Bahria Wided, Makhlouf Yasmine: Data collection, conceptualization, editing, Final approval of the version of the article to be published

  • - Others: Substantial contributions to analysis and interpretation of data, Final approval of the version of the article to be published

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Wided B, Yasmine M, Intissar B et al. Effect of Methocarbamol on acute low back pain: A systematic review [version 1; peer review: 2 not approved]. F1000Research 2024, 13:1139 (https://doi.org/10.12688/f1000research.156511.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
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Reviewer Report 28 Dec 2024
Zachary Cupler, Physical Medicine & Rehabilitative Services, Institute for Clinical Research Education, University of Pittsburgh, Butler VA Health Care System, Pennsylvania, USA;  Logan University, Chesterfield, Missouri, USA 
Tyler Snodgrass, Logan University, Chesterfield, Missouri, USA 
Not Approved
VIEWS 5
Thank you for the invitation to review “Effect of Methocarbamol on acute low back pain: A systematic review”. This systematic review assessed the effectiveness of methocarbamol in treating acute low back pain. The author’s major findings indicate that methocarbamol may ... Continue reading
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Cupler Z and Snodgrass T. Reviewer Report For: Effect of Methocarbamol on acute low back pain: A systematic review [version 1; peer review: 2 not approved]. F1000Research 2024, 13:1139 (https://doi.org/10.5256/f1000research.171834.r342495)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 20 Nov 2024
Thiru Annaswamy, Penn State Health Milton S. Hershey Medical Center, Physical Medicine & Rehabilitation, Penn State Health Rehabilitation Hospital, Pennsylvania, USA 
Andrew Chen, Physical Medicine & Rehabilitation, Penn State Health Milton S Hershey Medical Center (Ringgold ID: 12311), Hershey, Pennsylvania, USA 
Not Approved
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General Comments:
This is a SR on effect of Methacarbamol on acute low back pain.

The justification (need) for this systematic review of the effect of Methacarbamol on acute low back pain has not been well ... Continue reading
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Annaswamy T and Chen A. Reviewer Report For: Effect of Methocarbamol on acute low back pain: A systematic review [version 1; peer review: 2 not approved]. F1000Research 2024, 13:1139 (https://doi.org/10.5256/f1000research.171834.r337418)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

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Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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