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One fair-quality study showed no difference between metaxalone and placebo.19 Limited evidence exists to support the use of skeletal muscle relaxants in chronic low back pain.1720 Benzodiazepines have been effective for short-term use compared with placebo, but the basis of this recommendation stemmed from trials involving tetrazepam, which is not available in the United States.2126 One meta-analysis evaluated 14 studies comparing cyclobenzaprine with placebo for back and neck pain.27 The trials included were of less than 14 days' duration.

Cyclobenzaprine was found to be moderately more effective than placebo, but had more central nervous system adverse effects.

The placebo-controlled trials included 17 on cyclobenzaprine, six on tizanidine, four on carisoprodol, and four on orphenadrine, and were mostly conducted more than 15 years ago. Low-dose cyclobenzaprine versus combination therapy with ibuprofen for acute neck or back pain with muscle spasm: a randomized trial. Contact [email protected] copyright questions and/or permission requests.

The average patient enrollment was less than 150 patients (range 12 to 400 patients).

The authors also described several limitations of the meta-analysis including inadequate blinding, heterogeneity among studies, and the presence of publication bias.27 Overall, studies appear to be consistent, with cyclobenzaprine having greatest benefit within the first few days of treatment rather than at one or two weeks.1827Skeletal muscle relaxants have also been studied as adjunctive therapy to analgesics in treating acute low back pain.

In one open-label study (20 patients), the addition of cyclobenzaprine to naproxen (Naprosyn) resulted in a statistically significant decrease in muscle spasm and tenderness compared with naproxen alone.28 A Cochrane review analyzed three high-quality trials (560 total patients) that showed tizanidine plus analgesics was more effective in providing pain relief and decreasing muscle spasm than analgesics alone.17 Conversely, one low-quality open-label study (867 patients) comparing cyclobenzaprine alone (5 mg three times daily) versus combination with ibuprofen (Motrin; either 400 or 800 mg three times daily) showed that, although all groups improved at seven days, there was no statistical difference in outcomes among the groups.29 Nonetheless, the use of combination therapy has been supported in quickening recovery,17 with minimal overall risk of adverse effects (relative risk [RR] = 1.34; 95% confidence interval [CI], 0.67 to 2.67].20Cyclobenzaprine has also been studied in treating fibromyalgia.

In addition, these drugs have not been proven to be superior to acetaminophen or nonsteroidal anti-inflammatory drugs for low back pain.

Systematic reviews and meta-analyses support using skeletal muscle relaxants for short-term relief of acute low back pain when nonsteroidal anti-inflammatory drugs or acetaminophen are not effective or tolerated.

Methocarbamol and metaxalone are less sedating, although effectiveness evidence is limited.

Similar recommendations exist in treating tension headaches.13 A meta-analysis evaluating the use of cyclobenzaprine showed that, although this drug was better than placebo for the treatment of fibromyalgia, it was considered inferior to antidepressants.14 Additionally, recent guidelines on fibromyalgia recommend using a comprehensive approach that utilizes tramadol (Ultram), antidepressants, and/or a heated pool (with or without exercise).15Prescription rates for nonspecific back pain revealed that skeletal muscle relaxants accounted for 18.5 percent of prescriptions compared with 16.3 percent for NSAIDs and 10 percent for cyclooxygenase-2 inhibitors.16 Because of the high rate of prescribing skeletal muscle relaxants, an understanding of the risks and benefits of this class of drugs is vital.

This article presents evidence regarding the use of antispasmodic skeletal muscle relaxants for various musculoskeletal conditions, and appropriate drug selection if a skeletal muscle relaxant is required.

Highlights of contraindications, adverse effects, and drug interactions for these drugs are listed in Many of the studies evaluating the effectiveness of skeletal muscle relaxants are hampered by poor methodologic design, including incomplete reporting of compliance, improper or no mention of allocation concealment, not utilizing intention-to-treat methods, and inadequate randomization.1718 Nonetheless, skeletal muscle relaxants have been evaluated in systematic reviews and meta-analyses.

Some evidence appears to support nonbenzodiazepine skeletal muscle relaxants, such as carisoprodol, cyclobenzaprine, orphenadrine (Norflex), and tizanidine (Zanaflex), for acute low back pain.1718 Randomized controlled trials involving metaxalone have not been conducted since the 1970s.

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