{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,29]],"date-time":"2026-08-29T10:14:35Z","timestamp":1787998475398,"version":"build-2784847793"},"reference-count":32,"publisher":"Oxford University Press (OUP)","issue":"1188","license":[{"start":{"date-parts":[[2024,4,27]],"date-time":"2024-04-27T00:00:00Z","timestamp":1714176000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"funder":[{"name":"Health and Medical Research Fund of the Food and Health Bureau","award":["06170236"],"award-info":[{"award-number":["06170236"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,9,22]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Low back pain (LBP) is a leading cause of disability worldwide and has posed numerous health and socioeconomic challenges. This study compared whether nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with tramadol, tizanidine or placebo would be the best treatment regime to improve the Roland Morris Disability Questionnaire (RMDQ) scores at 1 week.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>This was a multi-center, double-blind, randomized, and placebo-controlled trial including adult patients with acute LBP and sciatica in three emergency departments in Hong Kong. Patients were randomized to the receive tramadol 50\u00a0mg, tizanidine 2\u00a0mg, or placebo every 6\u00a0hours for 2\u00a0weeks in a 1:1:1 ratio. The RMDQ and other secondary outcomes were measured at baseline, Day 2, 7, 14, 21, and 28. Data were analyzed on an intention to treat basis. Crude and adjusted mean differences in the changes of RMDQ and NRS scores from baseline to Day 7 between tizanidine\/tramadol and placebo were determined with 95% confidence intervals.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Two hundred and ninety-one patients were analyzed with the mean age of 47.4\u00a0years and 57.7% were male. The primary outcome of mean difference in RMDQs on Day 7 (compared with baseline) was non-significant for tizanidine compared with placebo (adjusted mean difference\u2009\u2212\u20090.56, 95% CI -2.48 to 1.37) and tramadol compared with placebo (adjusted mean difference\u2009\u2212\u20090.85, 95% CI -2.80 to 1.10). Only 23.7% were fully compliant to the treatment allocated. Complier Average Causal Effect analysis also showed no difference in the primary outcome for the tizanidine and tramadol versus placebo.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>Among patients with acute LBP and sciatica presenting to the ED, adding tramadol or tizanidine to diclofenac did not improve functional recovery.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/postmj\/qgae052","type":"journal-article","created":{"date-parts":[[2024,4,29]],"date-time":"2024-04-29T03:45:07Z","timestamp":1714362307000},"page":"741-750","source":"Crossref","is-referenced-by-count":2,"title":["Comparison of diclofenac with tramadol, tizanidine or placebo in the treatment of acute low back pain and sciatica: multi-center randomized controlled trial"],"prefix":"10.1093","volume":"100","author":[{"given":"Kevin K C","family":"Hung","sequence":"first","affiliation":[{"name":"Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong , 2\/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"},{"name":"Accident & Emergency Department, Prince of Wales Hospital , 2\/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"},{"name":"Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong , Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rex P K","family":"Lam","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine , Li Ka Shing Faculty of Medicine, , G06, G\/F, University of Hong Kong the Hong Kong Jockey Club Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong SAR, China , Hong Kong"},{"name":"The University of Hong Kong , Li Ka Shing Faculty of Medicine, , G06, G\/F, University of Hong Kong the Hong Kong Jockey Club Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong SAR, China , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Herman K H","family":"Lee","sequence":"additional","affiliation":[{"name":"Accident & Emergency Department, United Christian Hospital , 130 Hip Wo St, Kwun Tong, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yu Fai","family":"Choi","sequence":"additional","affiliation":[{"name":"Accident & Emergency Department, Pamela Youde Nethersole Eastern Hospital , 3 Lok Man Road, Chai Wan, Hong Kong , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justin","family":"Tenney","sequence":"additional","affiliation":[{"name":"School of Pharmacy, The Chinese University of Hong Kong , 8th Floor, Lo Kwee-Seong Integrated Biomedical Sciences Building Area 39, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong , Hong Kong"},{"name":"Pharmacy Department, Canberra Hospital , Yamba Drive Garran ACT 2605, Canberra , Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhong","family":"Zuo","sequence":"additional","affiliation":[{"name":"School of Pharmacy, The Chinese University of Hong Kong , 8th Floor, Lo Kwee-Seong Integrated Biomedical Sciences Building Area 39, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marc K C","family":"Chong","sequence":"additional","affiliation":[{"name":"Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong , Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Theresa S I","family":"Hui","sequence":"additional","affiliation":[{"name":"Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong , 2\/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tak Kan","family":"Wong","sequence":"additional","affiliation":[{"name":"Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong , 2\/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tsz Ying","family":"Yiu","sequence":"additional","affiliation":[{"name":"Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong , 2\/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Suet Yi","family":"Chan","sequence":"additional","affiliation":[{"name":"Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong , 2\/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Catherine P Y","family":"Mok","sequence":"additional","affiliation":[{"name":"Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong , 2\/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ling Yan","family":"Leung","sequence":"additional","affiliation":[{"name":"Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong , 2\/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wai Kit","family":"Mak","sequence":"additional","affiliation":[{"name":"Department of Surgery, The Chinese University of Hong Kong , Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David T F","family":"Sun","sequence":"additional","affiliation":[{"name":"Department of Surgery, The Chinese University of Hong Kong , Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chi Hung","family":"Cheng","sequence":"additional","affiliation":[{"name":"Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong , 2\/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"},{"name":"Accident & Emergency Department, Prince of Wales Hospital , 2\/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Colin A","family":"Graham","sequence":"additional","affiliation":[{"name":"Accident and Emergency Medicine Academic Unit, The Chinese University of Hong Kong , 2\/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"},{"name":"Accident & Emergency Department, Prince of Wales Hospital , 2\/F, Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"},{"name":"Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong , Prince of Wales Hospital, Shatin, NT, Hong Kong SAR , Hong Kong"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2024,4,27]]},"reference":[{"key":"2024092310064771100_ref1","doi-asserted-by":"crossref","first-page":"299","DOI":"10.21037\/atm.2020.02.175","article-title":"Global low back pain prevalence and years lived with disability from 1990 to 2017. Estimates from the global burden of disease study 2017","volume":"8","author":"Wu","year":"2020","journal-title":"Ann Translational Med"},{"key":"2024092310064771100_ref2","doi-asserted-by":"crossref","first-page":"1545","DOI":"10.1016\/S0140-6736(16)31678-6","article-title":"Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the global burden of disease study 2015","volume":"388","author":"Vos","year":"2016","journal-title":"Lancet"},{"key":"2024092310064771100_ref3","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1016\/j.spinee.2007.10.005","article-title":"A systematic review of low back pain cost of illness studies in the United States and internationally","volume":"8","author":"Dagenais","year":"2008","journal-title":"Spine J"},{"key":"2024092310064771100_ref4","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1016\/j.annemergmed.2011.09.012","article-title":"One-week and 3-month outcomes after an emergency department visit for undifferentiated musculoskeletal low back pain","volume":"59","author":"Friedman","year":"2012","journal-title":"Ann Emerg Med"},{"key":"2024092310064771100_ref5","doi-asserted-by":"crossref","first-page":"480","DOI":"10.7326\/M16-2458","article-title":"Systemic pharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline","volume":"166","author":"Chou","year":"2017","journal-title":"Ann Intern Med"},{"key":"2024092310064771100_ref6","doi-asserted-by":"crossref","first-page":"514","DOI":"10.7326\/M16-2367","article-title":"Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians","volume":"166","author":"Qaseem","year":"2017","journal-title":"Ann Intern Med"},{"key":"2024092310064771100_ref7","doi-asserted-by":"crossref","first-page":"2791","DOI":"10.1007\/s00586-018-5673-2","article-title":"Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview","volume":"27","author":"Oliveira","year":"2018","journal-title":"Eur Spine J"},{"key":"2024092310064771100_ref8","first-page":"Art. No.: CD013581","article-title":"Non-steroidal anti-inflammatory drugs for acute low back pain","author":"van der Gaag","year":"2020","journal-title":"Cochrane Database Syst Rev"},{"key":"2024092310064771100_ref9","article-title":"Efficacy, acceptability, and safety of muscle relaxants for adults with non-specific low back pain: systematic review and meta-analysis","volume":"374","author":"Cashin","year":"2021","journal-title":"BMJ"},{"key":"2024092310064771100_ref10","doi-asserted-by":"crossref","DOI":"10.1136\/bjsports-2018-099805","article-title":"Harms and benefits of opioids for management of non-surgical acute and chronic low back pain: a systematic review","volume":"54","author":"Tucker","year":"2020","journal-title":"Br J Sports Med"},{"key":"2024092310064771100_ref11","doi-asserted-by":"crossref","first-page":"304","DOI":"10.1016\/S0140-6736(23)00404-X","article-title":"Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial","volume":"402","author":"Jones","year":"2023","journal-title":"Lancet"},{"key":"2024092310064771100_ref12","doi-asserted-by":"crossref","first-page":"1572","DOI":"10.1001\/jama.2015.13043","article-title":"Naproxen with cyclobenzaprine, oxycodone\/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial","volume":"314","author":"Friedman","year":"2015","journal-title":"JAMA"},{"key":"2024092310064771100_ref13","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1016\/j.annemergmed.2017.09.031","article-title":"A randomized, double-blind, placebo-controlled trial of naproxen with or without Orphenadrine or Methocarbamol for acute low back pain","volume":"71","author":"Friedman","year":"2018","journal-title":"Ann Emerg Med"},{"key":"2024092310064771100_ref14","doi-asserted-by":"crossref","first-page":"512","DOI":"10.1016\/j.annemergmed.2019.02.017","article-title":"A randomized, placebo-controlled trial of ibuprofen plus metaxalone, tizanidine, or baclofen for acute low back pain","volume":"74","author":"Friedman","year":"2019","journal-title":"Ann Emerg Med"},{"key":"2024092310064771100_ref15","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1007\/s40122-019-0112-6","article-title":"Efficacy and safety of combination of NSAIDs and muscle relaxants in the management of acute low back pain","volume":"8","author":"Patel","year":"2019","journal-title":"Pain Ther"},{"key":"2024092310064771100_ref16","doi-asserted-by":"crossref","first-page":"685","DOI":"10.4184\/asj.2016.10.4.685","article-title":"Low-dose tramadol and non-steroidal anti-inflammatory drug combination therapy prevents the transition to chronic low back pain","volume":"10","author":"Inage","year":"2016","journal-title":"Asian Spine J"},{"key":"2024092310064771100_ref17","doi-asserted-by":"crossref","first-page":"464","DOI":"10.7326\/M14-2070","article-title":"Oral prednisolone in the treatment of acute gout: a pragmatic, multicenter, double-blind","volume":"164","author":"Rainer","year":"2016","journal-title":"Randomized Trial Ann Intern Med"},{"key":"2024092310064771100_ref18","doi-asserted-by":"crossref","first-page":"736","DOI":"10.1016\/S0140-6736(16)30970-9","article-title":"Non-specific low back pain","volume":"389","author":"Maher","year":"2017","journal-title":"Lancet"},{"key":"2024092310064771100_ref19","doi-asserted-by":"crossref","first-page":"3115","DOI":"10.1097\/00007632-200012150-00006","article-title":"The Roland-Morris disability questionnaire and the Oswestry disability questionnaire","volume":"25","author":"Roland","year":"2000","journal-title":"Spine (Phila Pa 1976)"},{"key":"2024092310064771100_ref20","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1016\/S1013-7025(09)70049-1","article-title":"Measurement properties of the Hong Kong Chinese version of the Roland-Morris disability questionnaire","volume":"22","author":"Tsang","year":"2004","journal-title":"Hong Kong Physiotherapy Journal"},{"key":"2024092310064771100_ref21","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1016\/j.jpain.2018.07.009","article-title":"Measurement properties of visual analogue scale, numeric rating scale, and pain severity subscale of the brief pain inventory in patients with low back pain: a systematic review","volume":"20","author":"Chiarotto","year":"2019","journal-title":"J Pain"},{"key":"2024092310064771100_ref22","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1097\/BRS.0b013e31815e3a10","article-title":"Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change","volume":"33","author":"Ostelo","year":"2008","journal-title":"Spine"},{"key":"2024092310064771100_ref23","doi-asserted-by":"crossref","first-page":"1836","DOI":"10.1007\/s00586-009-1019-4","article-title":"Aceclofenac-tizanidine in the treatment of acute low back pain: a double-blind, double-dummy, randomized, multicentric, comparative study against aceclofenac alone","volume":"18","author":"Pareek","year":"2009","journal-title":"Eur Spine J"},{"key":"2024092310064771100_ref24","doi-asserted-by":"crossref","first-page":"605","DOI":"10.1111\/j.1365-2125.1994.tb04311.x","article-title":"Frequency of human CYP2D6 mutant alleles in a normal Chinese population","volume":"37","author":"Lee","year":"1994","journal-title":"Br J Clin Pharmacol"},{"key":"2024092310064771100_ref25","doi-asserted-by":"crossref","first-page":"681","DOI":"10.1007\/s00228-015-1857-4","article-title":"Effect of the CYP2D6 gene polymorphism on postoperative analgesia of tramadol in Han nationality nephrectomy patients","volume":"71","author":"Dong","year":"2015","journal-title":"Eur J Clin Pharmacol"},{"key":"2024092310064771100_ref26","doi-asserted-by":"crossref","first-page":"E29","DOI":"10.1503\/cmaj.230542","article-title":"The clinical course of acute, subacute and persistent low back pain: a systematic review and meta-analysis","volume":"196","author":"Wallwork","year":"2024","journal-title":"CMAJ"},{"key":"2024092310064771100_ref27","doi-asserted-by":"crossref","first-page":"835","DOI":"10.1002\/ejp.1911","article-title":"Risk factors for low back pain outcome: does it matter when they are measured?","volume":"26","author":"Klyne","year":"2022","journal-title":"Eur J Pain"},{"key":"2024092310064771100_ref28","doi-asserted-by":"crossref","first-page":"2384","DOI":"10.1016\/S0140-6736(18)30488-4","article-title":"Low back pain: a call for action","volume":"391","author":"Buchbinder","year":"2018","journal-title":"Lancet"},{"key":"2024092310064771100_ref29","doi-asserted-by":"crossref","first-page":"1431","DOI":"10.1097\/j.pain.0000000000001250","article-title":"Importance of being collaborative for return to work with back pain","volume":"159","author":"Nicholas","year":"2018","journal-title":"Pain"},{"key":"2024092310064771100_ref30","doi-asserted-by":"crossref","first-page":"352","DOI":"10.1016\/j.annemergmed.2005.01.023","article-title":"Randomized double-blind trial comparing oral paracetamol and oral nonsteroidal antiinflammatory drugs for treating pain after musculoskeletal injury","volume":"46","author":"Woo","year":"2005","journal-title":"Ann Emerg Med"},{"key":"2024092310064771100_ref31","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1185\/03007990903426787","article-title":"Adverse event profile of tramadol in recent clinical studies of chronic osteoarthritis pain","volume":"26","author":"Langley","year":"2010","journal-title":"Curr Med Res Opin"},{"key":"2024092310064771100_ref32","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1177\/030006058801600201","article-title":"A multicentre placebo-controlled study in general practice to evaluate the efficacy and safety of tizanidine in acute low-back pain","volume":"16","author":"Berry","year":"1988","journal-title":"J Int Med Res"}],"container-title":["Postgraduate Medical Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/pmj\/advance-article-pdf\/doi\/10.1093\/postmj\/qgae052\/59226031\/qgae052.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/pmj\/advance-article-pdf\/doi\/10.1093\/postmj\/qgae052\/59226031\/qgae052.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,9,23]],"date-time":"2024-09-23T10:07:16Z","timestamp":1727086036000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/pmj\/article\/100\/1188\/741\/7659278"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,4,27]]},"references-count":32,"journal-issue":{"issue":"1188","published-online":{"date-parts":[[2024,4,27]]},"published-print":{"date-parts":[[2024,9,22]]}},"URL":"https:\/\/doi.org\/10.1093\/postmj\/qgae052","relation":{},"ISSN":["0032-5473","1469-0756"],"issn-type":[{"value":"0032-5473","type":"print"},{"value":"1469-0756","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2024,10]]},"published":{"date-parts":[[2024,4,27]]}}}