Central muscle relaxants: role and place in the treatment of back pain

December 21, 2021
Specialities :

Back pain is a condition that ranks first in the structure of pain syndromes and remains one of the most actual problems in medicine. In clinical practice, different pathophysiological variants of pain syndromes are often combined, which complicates the choice of optimal treatment.

Objective: to update information on the effectiveness and safety of central muscle relaxants (CMR) in the treatment of back pain, including tizanidine.

Object and methods of research: analysis of relevant sources of information on the effectiveness and safety of CMR, including tizanidine, in the treatment of back pain.

Results. To date, non-steroidal anti-inflammatory drugs (NSAIDs) and CMR have a high level of evidence for non-specific back pain among drugs. The main approaches to the use of CMR for back pain, as determined by clinical guidelines: clinical data do not confirm the superiority of one CMR over another in musculoskeletal system diseases; CMR are not considered first-line therapy in musculoskeletal diseases; in acute back pain as an adjunct therapy can be used CMR; in acute back pain, CMR should be used for a short time (2 weeks).

Conclusions. The results of the analysis of clinical trials in combination with the accumulated experience of clinical use confirm the effectiveness of CMR for the treatment of painful spasms, in particular for back pain. Among the existing CMR, tizanidine is an effective drug with an optimal safety profile, with the possibility of combined use with NSAIDs and the ability to reduce their gastrotoxicity.


  • 1. Bento T.P.F., Cornelio G.P., Perrucini P.O. et al. (2020) Low back pain in adolescents and association with sociodemographic factors, electronic devices, physical activity and mental health. J. Pediatr. (Rio J), 96(6): 717–724. DOI: 10.1016/j.jped.2019.07.008.
  • 2. Casiano V.E., Dydyk A.M., Varacallo M. (2021) Back Pain. In: StatPearls. Treasure Island (FL): StatPearls Publishing, PMID: 30844200.
  • 3. Lo J., Chan L., Flynn S.A. (2021) Systematic Review of the Incidence, Prevalence, Costs, and Activity and Work Limitations of Amputation, Osteoarthritis, Rheumatoid Arthritis, Back Pain, Multiple Sclerosis, Spinal Cord Injury, Stroke, and Traumatic Brain Injury in the United States: A 2019 Update. Arch. Phys. Med. Rehabil., 102(1): 115–131. DOI: 10.1016/j.apmr.2020.04.001.
  • 4. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research (2011) Washington (DC): National Academies Press.
  • 5. Schmidt C., Raspe H., Pfingsten M. et al. (2007) Back pain in the German adult population. Spine, 37(18): 2005–2011.
  • 6. Podchufarova E.V. (2012) Back pain: mechanisms of development and treatment. Modern therapy in psychiatry and neurology, 3: 47–54.
  • 7. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine (2010) Anesthesiology, 112(4): 810–833.
  • 8. Chou R., Deyo R., Friedly J. et al. (2017) Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann. Intern. Med., 166(7): 480–492. DOI: 10.7326/M16-2458.
  • 9. Abdel Shaheed C., Maher C.G., Williams K.A. et al. (2016) Efficacy and tolerability of muscle relaxants for low back pain: Systematic review and meta-analysis. Eur. J. Pain, 21(2): 228–237. DOI: 10.1002/ejp.907.
  • 10. Cashin A.G., Folly T., Bagg M. K. et al. (2021) Efficacy, acceptability, and safety of muscle relaxants for adults with non-specific low back pain: systematic review and meta-analysis. BMJ, 374: n1446. DOI: 10.1136/bmj.n1446.
  • 11. Amaechi O., Huffman M..M., Featherstone K. (2021) Pharmacologic Therapy for Acute Pain. Am Fam Physician. 2021 Jul 1; 104(1): 63–72. PMID: 34264611.
  • 12. See S., Ginzburg R. (2008) Choosing a skeletal muscle relaxant. Am. Fam. Physician, 78(3): 365–370. PMID: 18711953.
  • 13. Chou R., Peterson K., Helfand M. (2004) Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: a systematic review. J. Pain Symptom. Manage, 28(2): 140–175. DOI: 10.1016/j.jpainsymman.2004.05.002. PMID: 15276195.
  • 14. Zygmunt M., Sapa J. (2015) Muscle relaxants — the current position in the treatment of spasticity in orthopedics. Ortop. Traumatol. Rehabil., 17(4): 423–430. DOI: 10.5604/15093492.1173500. PMID: 26468180.
  • 15. Schreijenberg M., Koes B.W., Lin C.C. (2019) Guideline recommendations on the pharmacological management of non-specific low back pain in primary care — is there a need to change? Expert Rev. Clin. Pharmacol., 12(2): 145–157. DOI: 10.1080/17512433.2019.1565992. Epub 2019 Jan 16. PMID: 30618319.
  • 16. Podchufarova E.V., Yakhno N.N. (2010) Back pain. GOETAR-Media, Moscow, 368 p.
  • 17. Heinzlef O., Monteil-Roch I. (2012) Traitement médicamenteux de la spasticité dans la sclérose en plaques [Pharmacological treatment of spasticity in multiple sclerosis]. Rev. Neurol. (Paris), 168 Suppl. 3: S62–S68. doi: 10.1016/S0035-3787(12)70049-8. PMID: 22721367.
  • 18. Peck J., Urits I., Crane J. et al. (2020) Oral Muscle Relaxants for the Treatment of Chronic Pain Associated with Cerebral Palsy. Psychopharmacol. Bull., 50(4 Suppl. 1): 142–162. PMID: 33633423; PMCID: PMC7901132.
  • 19. Abdel Shaheed C., Maher C.G., Williams K.A. et al. (2017) Efficacy and tolerability of muscle relaxants for low back pain: Systematic review and meta-analysis. Eur. J. Pain, 21(2): 228–237.
  • 20. Cashin A.G., Folly T., Bagg M.K. et al. (2021) Efficacy, acceptability, and safety of muscle relaxants for adults with non-specific low back pain: systematic review and meta-analysis. BMJ. 2021 Jul 7; 374: n1446.
  • 21. Chou R,.Qaseem A., Snow V. et al. (2008) Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann. Intern. Med., 148(3): 247–248.
  • 22. Chou R., Kim P. (2005) Drug Class Review on Skeletal Muscle Relaxants. http://www.ohsu.edu/ohsuedu/research/policycenter/DERP/about/methods.cfm
  • 23. compendium.com.ua/dec/272742/
  • 24. compendium.com.ua/dec/265520/
  • 25. compendium.com.ua/dec/260727/
  • 26. compendium.com.ua/dec/351869/
  • 27. compendium.com.ua/dec/265593/
  • 28. compendium.com.ua/dec/272742/
  • 29. Efficacy and gastroprotective effects of tizanidine plus diclofenac versus placebo plus diclofenac in patients with painful muscle spasms (1998) Current Therapeutic Research, 59(1): 13–22.
  • 30. Pareek A., Chandurkar N.,Chandanwale A.S. et al. (2009) Aceclofenac–tizanidine in the treatment of acute low back pain: a double-blind, double-dummy, randomized, multicentric, comparative study against aceclofenac alone. Eur. Spine J., 18(12): 1836–1842.
  • 31. Berry H., Hutchinson D.R. (1988) Tizanidine and ibuprofen in acute low-back pain: results of a double-blind multicentre study in general practice. J. Int. Med. Res., 16(2): 83–91. DOI: 10.1177/030006058801600202.
  • 32. Dzyak L.A., Suk V.M., Tsurkalenko A.S. (2009) Treatment of muscle spasm using the drug Tizalud. Health of Ukraine, 62–63.
  • 33. Klimovich LF, Fedotova IF (2009) Tizalud in the complex treatment of patients with multiple sclerosis. Ukr. Bull. Psychoneurol., 17(59): 84–87.
  • 34. Bozhenko N.L. (2012) Tizalud in the treatment of myofascial pain dysfunction. Acute and Urgent Conditions in Physician Practice, 1: 21–24.