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

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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 " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/13-1139", "name": "Effect of Methocarbamol on acute low back pain: A systematic review" } } ] } Home Browse Effect of Methocarbamol on acute low back pain: A systematic review ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article 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. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Systematic Review Effect of Methocarbamol on acute low back pain: A systematic review [version 1; peer review: 2 not approved] Bahria Wided 1,2 , Makhlouf Yasmine 2,3 , Boussaid Intissar 1,2 , Walha Yasmine 1,2 , Nouira Nour Elhouda 1,2 , Laater Ahmed 2,3 Bahria Wided 1,2 , Makhlouf Yasmine 2,3 , [...] Boussaid Intissar 1,2 , Walha Yasmine 1,2 , Nouira Nour Elhouda 1,2 , Laater Ahmed 2,3 PUBLISHED 07 Oct 2024 Author details Author details 1 Department of Emergency, Mongi Slim Hospital, La Marsa, University Tunis Elmanar, Tunis, Tunis, 2046, Tunisia 2 Faculty of medicine, University Tunis Elmanar, Tunis, Tunisia 3 Department of rheumatology, Mongi Slim Hospital, La Marsa, University Tunis Elmanar, Tunis, Tunis, 2046, Tunisia Bahria Wided Roles: Conceptualization, Methodology, Writing – Review & Editing Makhlouf Yasmine Roles: Conceptualization, Funding Acquisition, Writing – Review & Editing Boussaid Intissar Roles: Formal Analysis, Resources, Visualization Walha Yasmine Roles: Funding Acquisition, Visualization, Writing – Review & Editing Nouira Nour Elhouda Roles: Funding Acquisition, Validation, Writing – Original Draft Preparation Laater Ahmed Roles: Funding Acquisition, Resources, Writing – Original Draft Preparation OPEN PEER REVIEW DETAILS REVIEWER STATUS 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 READ ALL READ LESS Keywords Methocarbamol, Back pain, Acute Corresponding Author(s) Bahria Wided ( [email protected] ) Close Corresponding author: Bahria Wided Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Wided B et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: 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 ) First published: 07 Oct 2024, 13 :1139 ( https://doi.org/10.12688/f1000research.156511.1 ) Latest published: 07 Oct 2024, 13 :1139 ( https://doi.org/10.12688/f1000research.156511.1 ) 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 pain Synonyms 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. 11 – 13 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 studies 4 – 6 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 64 12 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. Baseline At 30 min At 60 min At 1 week At 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 irritation 11 and dizziness. However, side effects were comparable between the groups 11 , 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 Data availability statement Reporting guidelines Figshare: Effect of Methocarbamol on acute low back pain: A systematic review. Dataset for analysis: DOI: https://doi.org/10.6084/m9.figshare.27073633.v7 . 19 This project contains following datasets: 1. Flow chart fig 1 2. Prisma Checklist Guidelines table 2 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Extended data Figshare: Effect of Methocarbamol on acute low back pain: A systematic review. Dataset for analysis: DOI: https://doi.org/10.6084/m9.figshare.27073633.v7 . 19 This project contains following extended datasets: 1. Characteristics of the studies Table 1 2. Biasis risk Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). References 1. Kreiner DS, Matz P, Bono CM, et al. : Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J. 2021 Apr; 21 (4): 726–727. PubMed Abstract | Publisher Full Text 2. Kahere M, Ngcamphalala C, Östensson E, et al. : The economic burden of low back pain in KwaZulu-Natal, South Africa: A prevalence-based cost-of-illness analysis from the healthcare provider’s perspective. PLoS One. 2022; 17 (10): e0263204. PubMed Abstract | Publisher Full Text | Free Full Text 3. Wu A, March L, Zheng X, et al. : Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med. 2020; 8 (6): 299. PubMed Abstract | Publisher Full Text | Free Full Text 4. Strudwick K, McPhee M, Bell A, et al. : Review article: Best practice management of low back pain in the emergency department (part 1 of the musculoskeletal injuries rapid review series). Emerg Med Australas EMA. 2018; 30 (1): 18–35. PubMed Abstract | Publisher Full Text 5. Waterman BR, Belmont PJ, Schoenfeld AJ: Low back pain in the United States: incidence and risk factors for presentation in the emergency setting. Spine J Off J North Am Spine Soc. 2012; 12 (1): 63–70. PubMed Abstract | Publisher Full Text 6. Price MR, Cupler ZA, Hawk C, et al. : Systematic review of guideline-recommended medications prescribed for treatment of low back pain. Chiropr Man Ther. 13 mai 2022; 30 (1): 26. PubMed Abstract | Publisher Full Text | Free Full Text 7. Emrich OMD, Milachowski KA, Strohmeier M: Methocarbamol in acute low back pain. A randomized double-blind controlled study. MMW Fortschr Med. juill 2015; 157 Suppl 5 : 9–16. PubMed Abstract | Publisher Full Text 8. Aljuhani O, Kopp BJ, Patanwala AE: Effect of Methocarbamol on Acute Pain After Traumatic Injury. Am J Ther. 2017; 24 (2): e202–e206. PubMed Abstract | Publisher Full Text 9. Page MJ, McKenzie JE, Bossuyt PM, et al. : The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; 372 : n71. Publisher Full Text 10. Risk of Bias 2 (RoB 2) tool|Cochrane Methods.[cité 24 févr 2024]. 11. Friedman BW, Cisewski D, Irizarry E, et al. : A Randomized, Double-Blind, Placebo-Controlled Trial of Naproxen With or Without Orphenadrine or Methocarbamol for Acute Low Back Pain. Ann Emerg Med. 2018; 71 (3): 348–356. e5. PubMed Abstract | Publisher Full Text | Free Full Text 12. Samsamshariat S, Sharifi-Sade M, Zoofaghari S, et al. : Efficacy of the Combination of Indomethacin and Methocarbamol versus Indomethacin Alone in Patients with Acute Low Back Pain: A Double-Blind, Randomized Placebo-Controlled Clinical Trial. J Res Pharm Pract. 2021; 10 (2): 96–101. PubMed Abstract | Publisher Full Text | Free Full Text 13. Sharifi M, Abdorazzaghnejad A, Yazdchi M, et al. : Methocarbamol versus diazepam in acute low back pain in the emergency department: a randomised double-blind clinical trial. Emerg Med J EMJ. juill 2023; 40 (7): 493–498. PubMed Abstract | Publisher Full Text 14. Wewege MA, Bagg MK, Jones MD, et al. : Comparative effectiveness and safety of analgesic medicines for adults with acute non-specific low back pain: systematic review and network meta-analysis. BMJ. 22 mars 2023 [cité 25 févr 2024]; 380 : e072962. PubMed Abstract | Publisher Full Text | Free Full Text 15. Anderson DB, Shaheed CA: Medications for Treating Low Back Pain in Adults. Evidence for the Use of Paracetamol, Opioids, Nonsteroidal Anti-inflammatories, Muscle Relaxants, Antibiotics, and Antidepressants: An Overview for Musculoskeletal Clinicians. J Orthop Sports Phys Ther. juill 2022; 52 (7): 425–431. PubMed Abstract | Publisher Full Text 16. Jones CMP, Day RO, Koes BW, et al. : Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomised placebo-controlled trial. Lancet Lond Engl. 22 juill 2023; 402 (10398): 304–312. Publisher Full Text 17. Beebe FA, Barkin RL, Barkin S: A clinical and pharmacologic review of skeletal muscle relaxants for musculoskeletal conditions. Am J Ther. 2005; 12 (2): 151–171. PubMed Abstract | Publisher Full Text 18. van Tulder MW , Touray T, Furlan AD, et al. : Muscle relaxants for non-specific low-back pain. Cochrane Database Syst. Rev. 2003; 2017 : CD004252. Publisher Full Text 19. Bahria W, Bahria W: PRISMA _2020_checklist. Dataset. figshare. 2024. Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 07 Oct 2024 ADD YOUR COMMENT Comment Author details Author details 1 Department of Emergency, Mongi Slim Hospital, La Marsa, University Tunis Elmanar, Tunis, Tunis, 2046, Tunisia 2 Faculty of medicine, University Tunis Elmanar, Tunis, Tunisia 3 Department of rheumatology, Mongi Slim Hospital, La Marsa, University Tunis Elmanar, Tunis, Tunis, 2046, Tunisia Bahria Wided Roles: Conceptualization, Methodology, Writing – Review & Editing Makhlouf Yasmine Roles: Conceptualization, Funding Acquisition, Writing – Review & Editing Boussaid Intissar Roles: Formal Analysis, Resources, Visualization Walha Yasmine Roles: Funding Acquisition, Visualization, Writing – Review & Editing Nouira Nour Elhouda Roles: Funding Acquisition, Validation, Writing – Original Draft Preparation Laater Ahmed Roles: Funding Acquisition, Resources, Writing – Original Draft Preparation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 07 Oct 2024, 13:1139 https://doi.org/10.12688/f1000research.156511.1 Copyright © 2024 Wided B et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article 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. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE 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 Version 1 VERSION 1 PUBLISHED 07 Oct 2024 Views 0 Cite How to cite this report: 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 ) The direct URL for this report is: https://f1000research.com/articles/13-1139/v1#referee-response-342495 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details 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 0 https://doi.org/10.5256/f1000research.171834.r342495 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 READ ALL 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 be useful in the short term for acute low back pain. This submission aligns with F1000’s scope. The methods of are appropriate to the research question. There are a number of major concerns we wish to draw the authors’ attention to that we believe are fundamentally necessary to improve this manuscript. Major comments Introduction The framing in the introduction does give robust reasoning for why this systematic review is needed. Please expand on the current state of the use of pharmacotherapy for acute low back pain and the current gaps in the literature, thus providing better support for the investigating primary inquiry regarding methocarbamol. What disagreements remain? See Price et al. regarding a review of guideline recommendations for skeletal muscle relaxants. Contrary to what is stated, this is not the first systematic review to evaluate skeletal muscle relaxant effectiveness for acute low back pain. Please revise and cite other studies in which the use of skeletal muscle relaxants is evaluated in ALBP. Reframing the statement that this is to first to “solely” assesses methocarbamol may better display the novelty of this research question. The American College of Physicians’ landmark paper recommends an array of pharmacological and non-pharmacological interventions including exercise, manual therapy, yoga, and tai chi for acute low back pain. Please consider revising paragraph 1-2 of the introduction Refer 1 and 2. Regarding the objective, “we conducted this systematic review to present the most up-to-date published literature on the effectiveness of methocarbamol in treating ALBP”. Was this limited to adults, adolescents, or adult and children? Please revise for clarity. Methods At least one full database string strategy should be reported. Please add as a table or appendix. A ‘PICO question’ format would serve to better guide the reporting of this study. Consider revising. What is the defined duration of acute low back pain for the purposes of this study? This should be introduced in the introduction and/or at the very least in the methods (Selection Criteria). Further, for results, as duration definitions of ALBP may vary between studies, describing the acute duration time frame for each study is valuable to the reader. The content of “Data extraction and quality assessment” in Methods seems to be transposed and should be included in “Selection criteria” instead. “Publications that did not align…” up to “… the inclusion criteria were excluded.” Please revise for consistency in reporting for Selection Criteria. This should include inclusion and exclusion criteria. Was screening of title/abstract and full-text paper performed by one author or multiple authors in duplicate? Please revise and clarify. Best practice is to perform in duplicate independently whereby consensus is met. Were the extraction and risk of bias steps performed by one author or multiple authors in duplicate? Please revise and clarify. Best practice is to perform in duplicate independently whereby consensus is met. Trauma is indicated as an exclusion reason in the results, but trauma is not mentioned as an inclusion or exclusion criteria in the methods. Please clarify. Radicular pain is indicated as an exclusion reason in the results, but radicular pain is not mentioned as an inclusion or exclusion criteria in the methods. Please clarify. Results There is marked inconsistency between Fig1 Flow Chart and Results. “…we identified 104 papers through the database. After removing duplicates, we screened 4 titles and abstracts.” Vs. Flow Chart indicates 136 papers were identified, 7 papers were reviewed for title and abstract and 3 were excluded. The recorded exclusion reasons make no sense because it appears this would meet the described objective of the paper. Finally, the Fig 1 Flow Chart is incomplete and has missing information. Primary and secondary outcomes were not specifically described in the Methods. It appears that evaluating the use of methocarbamol for relieving pain is the primary outcome per the abstract only; however, disability and adverse events are discussed as well, and function is highlighted at length in the Results. Please revise to resolve these discrepancies. “Exclusion criteria included non-traumatic ALBP for all studies 4-6 and the presence of radicular pain in the study by Benjamin W. et al.” does not make sense in the context of the 3 papers reviewed in this SR. Comments are previously noted regarding trauma and radicular pain which should be reconciled with this comment. Please clarify. The second paragraph of the results, “The effect of Methocarbamol on pain and functional disability”, contrasts pain scores and functional scores, which does not make sense in the context of the research question or methods. Please clarify and consider with previous comments regarding primary and secondary outcomes. Table 2: Define “N”, “3M” and “CI.”. Paragraph 3 of the Discussion is copy/paste information stated twice. Please revise for clarity. “ 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 systematic reviews 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 ” Two systematic reviews are cited in paragraph 3 of the Discussion that would be useful sources in the Introduction to help differentiate previous studies on skeletal muscle relaxants, and how this study intends to solely discuss methocarbamol. There are several concerns with accuracy of information in Paragraph 4 of Discussion. Use of citation 2 (discussing economic burden of low back pain) does not make sense in the context of sentence. Please revise and accurately cite. Citation 18 inaccurately supports a statement regarding methocarbamol when the review supports only non-specific skeletal muscle relaxants, not methocarbamol in particular. “Similarly, current evidence suggests that Methocarbamol may be more beneficial when used alongside other therapeutic modalities, particularly analgesics and NSAIDs”. This is somewhat misleading. Please revise. The authors state “strong evidence” based on what was found in this review. This is inaccurate and inappropriate use of the terminology considering this study did not include the appraisal of the strength of evidence for various conclusions using a rating system based on the quality and outcomes of the studies included. Please revise. The second sentence of Conclusion is likely truncated. Please expand. Minor comments Introduction Consider defining a level 1 analgesics (i.e., ). Methods: Typo “studiesand” Selection criteria: “3)” does not make sense in context. May be an issue with the transposed information. Extended data 1: “N=”, needs number Characteristics of patients: “[32-81]” does not make sense in context. Results: “For this update,” does not make sense in context. “BPFS” is defined twice, and may lead to confusion for readers. Please remove the second defining location. There is also the use of “Shiva et al.” which is not a reference cited. This citation should be listed as “Samsamshariat et al.” if referring to citation 12, as it stands in the text. The effect of Methocarbamol on pain and functional disability: please define the acronym “RMDQ” in the text prior; typos “comparable” and “measuring” Discussion: “Cochrane tool risk assessment bias” – already defined previously as “RoB2” Typo “address” Conclusion: Tense is incorrect. “…may improved pain in patients”. Extended Data: Typo: “Biasis risk”. Please revise. Table 1: Column 2 “Study Design” The mean age is represented and then there is an additional number in parentheses. It is unclear what this represents. See Friedman row – what does ‘12’ represent Methocarbamol : 81, (38 (12)) Flow Chart Figure 1: “Records after duplicates removed” is missing a numeric value for n= as is “Embase (n= )”. Please revise. Was citation searching performed forward and backward or unidirectional? Please specify. A German language paper was excluded. Search strategy indicates only papers written in English were considered. Consider revision to the Selection Criteria section. Are the rationale for, and objectives of, the Systematic Review clearly stated? Partly Are sufficient details of the methods and analysis provided to allow replication by others? Partly Is the statistical analysis and its interpretation appropriate? Not applicable Are the conclusions drawn adequately supported by the results presented in the review? No If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Not applicable References 1. Qaseem A, McLean RM, O'Gurek D, Batur P, et al.: Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family Physicians. Ann Intern Med . 2020; 173 (9): 739-748 PubMed Abstract | Publisher Full Text 2. Wilt T, Crandall C, Qaseem A: Correction: Previously Undisclosed Potential Conflict of Interest by an Author of American College of Physicians Clinical Guidelines. Annals of Internal Medicine . 2023; 176 (4). Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: guideline recommend non-pharmacological and pharmacological management of acute low back pain We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT 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 ) The direct URL for this report is: https://f1000research.com/articles/13-1139/v1#referee-response-342495 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: 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 ) The direct URL for this report is: https://f1000research.com/articles/13-1139/v1#referee-response-337418 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details 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 VIEWS 0 https://doi.org/10.5256/f1000research.171834.r337418 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 READ ALL 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 supported. The authors detail that the mechanism of action of methocarbamol is not understood, but doing a SR on its effectiveness does not answer mechanism of action questions. The authors mention "disagreements regarding prescription" and "...lack of clear consensus on its appropriateness", but don't substantiate this any further with citations and or additional details. In the discussion section, they cite 2 recent systematic review articles both of whom include muscle relaxants including methocarbamol in their scope. Therefore, it is unclear why this review focusing on Methacarbamol alone is clearly needed. Specific comments: Under "search strategy", please provide your definition of "acute low back pain" and describe if you included review of this definition in your article search. Please rewrite: "did not align in compliance with the purpose...", "were manually identifying", "Data extraction and quality assessment Extracted..." How were "disagreements resolved"? Under "Characteristics of Studies", why was "non-traumatic ALBP" pointed out? Was traumatic ALBP an inclusion criterion in your review? Edit typos in "comparabke" and "measauring" BPFS is defined two different ways. Please provide only one definition for this acronym. Under "Discussion" section, you mention "recent literature"... however, your search strategy is not "recent". Please explain. Rewrite 3rd paragraph of this section. It is redundant and unclear the way it is currently written. Cite the "several guidelines" you mention in this paragraph. How does your review compare to the 2 SRs you mention in this paragraph? Add space between "systematicreviews" "This was corroborated in our review...". Re-word this line. I am not sure if the results of this review are sufficient to make a statement that there is "strong evidence" for combined treatment with Methacarbamol and NSAIDs Table 2: Please define "N" and "CI" Please add column titles for columns 1 & 2. Please reword rest of column titles, which are unclear as currently defined. Are the rationale for, and objectives of, the Systematic Review clearly stated? Partly Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Not applicable Are the conclusions drawn adequately supported by the results presented in the review? Partly If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: 25 plus years of clinical and research expertise in evaluation and management of low back pain and related disorders We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT 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 ) The direct URL for this report is: https://f1000research.com/articles/13-1139/v1#referee-response-337418 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 07 Oct 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline 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 Reviewer Reports Invited Reviewers 1 2 Version 1 07 Oct 24 read read Thiru Annaswamy , Penn State Health Milton S. Hershey Medical Center, Physical Medicine & Rehabilitation, Penn State Health Rehabilitation Hospital, Pennsylvania, USA Andrew Chen , Penn State Health Milton S Hershey Medical Center (Ringgold ID: 12311), Hershey, USA Zachary Cupler , Institute for Clinical Research Education, University of Pittsburgh, Butler VA Health Care System, Pennsylvania, USA; Logan University, Chesterfield, USA Tyler Snodgrass , Logan University, Chesterfield, USA Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Cupler Z et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 28 Dec 2024 | for Version 1 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 0 Views copyright © 2024 Cupler Z et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline 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 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 be useful in the short term for acute low back pain. This submission aligns with F1000’s scope. The methods of are appropriate to the research question. There are a number of major concerns we wish to draw the authors’ attention to that we believe are fundamentally necessary to improve this manuscript. Major comments Introduction The framing in the introduction does give robust reasoning for why this systematic review is needed. Please expand on the current state of the use of pharmacotherapy for acute low back pain and the current gaps in the literature, thus providing better support for the investigating primary inquiry regarding methocarbamol. What disagreements remain? See Price et al. regarding a review of guideline recommendations for skeletal muscle relaxants. Contrary to what is stated, this is not the first systematic review to evaluate skeletal muscle relaxant effectiveness for acute low back pain. Please revise and cite other studies in which the use of skeletal muscle relaxants is evaluated in ALBP. Reframing the statement that this is to first to “solely” assesses methocarbamol may better display the novelty of this research question. The American College of Physicians’ landmark paper recommends an array of pharmacological and non-pharmacological interventions including exercise, manual therapy, yoga, and tai chi for acute low back pain. Please consider revising paragraph 1-2 of the introduction Refer 1 and 2. Regarding the objective, “we conducted this systematic review to present the most up-to-date published literature on the effectiveness of methocarbamol in treating ALBP”. Was this limited to adults, adolescents, or adult and children? Please revise for clarity. Methods At least one full database string strategy should be reported. Please add as a table or appendix. A ‘PICO question’ format would serve to better guide the reporting of this study. Consider revising. What is the defined duration of acute low back pain for the purposes of this study? This should be introduced in the introduction and/or at the very least in the methods (Selection Criteria). Further, for results, as duration definitions of ALBP may vary between studies, describing the acute duration time frame for each study is valuable to the reader. The content of “Data extraction and quality assessment” in Methods seems to be transposed and should be included in “Selection criteria” instead. “Publications that did not align…” up to “… the inclusion criteria were excluded.” Please revise for consistency in reporting for Selection Criteria. This should include inclusion and exclusion criteria. Was screening of title/abstract and full-text paper performed by one author or multiple authors in duplicate? Please revise and clarify. Best practice is to perform in duplicate independently whereby consensus is met. Were the extraction and risk of bias steps performed by one author or multiple authors in duplicate? Please revise and clarify. Best practice is to perform in duplicate independently whereby consensus is met. Trauma is indicated as an exclusion reason in the results, but trauma is not mentioned as an inclusion or exclusion criteria in the methods. Please clarify. Radicular pain is indicated as an exclusion reason in the results, but radicular pain is not mentioned as an inclusion or exclusion criteria in the methods. Please clarify. Results There is marked inconsistency between Fig1 Flow Chart and Results. “…we identified 104 papers through the database. After removing duplicates, we screened 4 titles and abstracts.” Vs. Flow Chart indicates 136 papers were identified, 7 papers were reviewed for title and abstract and 3 were excluded. The recorded exclusion reasons make no sense because it appears this would meet the described objective of the paper. Finally, the Fig 1 Flow Chart is incomplete and has missing information. Primary and secondary outcomes were not specifically described in the Methods. It appears that evaluating the use of methocarbamol for relieving pain is the primary outcome per the abstract only; however, disability and adverse events are discussed as well, and function is highlighted at length in the Results. Please revise to resolve these discrepancies. “Exclusion criteria included non-traumatic ALBP for all studies 4-6 and the presence of radicular pain in the study by Benjamin W. et al.” does not make sense in the context of the 3 papers reviewed in this SR. Comments are previously noted regarding trauma and radicular pain which should be reconciled with this comment. Please clarify. The second paragraph of the results, “The effect of Methocarbamol on pain and functional disability”, contrasts pain scores and functional scores, which does not make sense in the context of the research question or methods. Please clarify and consider with previous comments regarding primary and secondary outcomes. Table 2: Define “N”, “3M” and “CI.”. Paragraph 3 of the Discussion is copy/paste information stated twice. Please revise for clarity. “ 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 systematic reviews 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 ” Two systematic reviews are cited in paragraph 3 of the Discussion that would be useful sources in the Introduction to help differentiate previous studies on skeletal muscle relaxants, and how this study intends to solely discuss methocarbamol. There are several concerns with accuracy of information in Paragraph 4 of Discussion. Use of citation 2 (discussing economic burden of low back pain) does not make sense in the context of sentence. Please revise and accurately cite. Citation 18 inaccurately supports a statement regarding methocarbamol when the review supports only non-specific skeletal muscle relaxants, not methocarbamol in particular. “Similarly, current evidence suggests that Methocarbamol may be more beneficial when used alongside other therapeutic modalities, particularly analgesics and NSAIDs”. This is somewhat misleading. Please revise. The authors state “strong evidence” based on what was found in this review. This is inaccurate and inappropriate use of the terminology considering this study did not include the appraisal of the strength of evidence for various conclusions using a rating system based on the quality and outcomes of the studies included. Please revise. The second sentence of Conclusion is likely truncated. Please expand. Minor comments Introduction Consider defining a level 1 analgesics (i.e., ). Methods: Typo “studiesand” Selection criteria: “3)” does not make sense in context. May be an issue with the transposed information. Extended data 1: “N=”, needs number Characteristics of patients: “[32-81]” does not make sense in context. Results: “For this update,” does not make sense in context. “BPFS” is defined twice, and may lead to confusion for readers. Please remove the second defining location. There is also the use of “Shiva et al.” which is not a reference cited. This citation should be listed as “Samsamshariat et al.” if referring to citation 12, as it stands in the text. The effect of Methocarbamol on pain and functional disability: please define the acronym “RMDQ” in the text prior; typos “comparable” and “measuring” Discussion: “Cochrane tool risk assessment bias” – already defined previously as “RoB2” Typo “address” Conclusion: Tense is incorrect. “…may improved pain in patients”. Extended Data: Typo: “Biasis risk”. Please revise. Table 1: Column 2 “Study Design” The mean age is represented and then there is an additional number in parentheses. It is unclear what this represents. See Friedman row – what does ‘12’ represent Methocarbamol : 81, (38 (12)) Flow Chart Figure 1: “Records after duplicates removed” is missing a numeric value for n= as is “Embase (n= )”. Please revise. Was citation searching performed forward and backward or unidirectional? Please specify. A German language paper was excluded. Search strategy indicates only papers written in English were considered. Consider revision to the Selection Criteria section. Are the rationale for, and objectives of, the Systematic Review clearly stated? Partly Are sufficient details of the methods and analysis provided to allow replication by others? Partly Is the statistical analysis and its interpretation appropriate? Not applicable Are the conclusions drawn adequately supported by the results presented in the review? No If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Not applicable References 1. Qaseem A, McLean RM, O'Gurek D, Batur P, et al.: Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family Physicians. Ann Intern Med . 2020; 173 (9): 739-748 PubMed Abstract | Publisher Full Text 2. Wilt T, Crandall C, Qaseem A: Correction: Previously Undisclosed Potential Conflict of Interest by an Author of American College of Physicians Clinical Guidelines. Annals of Internal Medicine . 2023; 176 (4). Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise guideline recommend non-pharmacological and pharmacological management of acute low back pain We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Cupler Z and Snodgrass T. Peer Review 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 this citation. The direct URL for this report is: https://f1000research.com/articles/13-1139/v1#referee-response-342495 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Annaswamy T et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 20 Nov 2024 | for Version 1 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 0 Views copyright © 2024 Annaswamy T et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline 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 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 supported. The authors detail that the mechanism of action of methocarbamol is not understood, but doing a SR on its effectiveness does not answer mechanism of action questions. The authors mention "disagreements regarding prescription" and "...lack of clear consensus on its appropriateness", but don't substantiate this any further with citations and or additional details. In the discussion section, they cite 2 recent systematic review articles both of whom include muscle relaxants including methocarbamol in their scope. Therefore, it is unclear why this review focusing on Methacarbamol alone is clearly needed. Specific comments: Under "search strategy", please provide your definition of "acute low back pain" and describe if you included review of this definition in your article search. Please rewrite: "did not align in compliance with the purpose...", "were manually identifying", "Data extraction and quality assessment Extracted..." How were "disagreements resolved"? Under "Characteristics of Studies", why was "non-traumatic ALBP" pointed out? Was traumatic ALBP an inclusion criterion in your review? Edit typos in "comparabke" and "measauring" BPFS is defined two different ways. Please provide only one definition for this acronym. Under "Discussion" section, you mention "recent literature"... however, your search strategy is not "recent". Please explain. Rewrite 3rd paragraph of this section. It is redundant and unclear the way it is currently written. Cite the "several guidelines" you mention in this paragraph. How does your review compare to the 2 SRs you mention in this paragraph? Add space between "systematicreviews" "This was corroborated in our review...". Re-word this line. I am not sure if the results of this review are sufficient to make a statement that there is "strong evidence" for combined treatment with Methacarbamol and NSAIDs Table 2: Please define "N" and "CI" Please add column titles for columns 1 & 2. Please reword rest of column titles, which are unclear as currently defined. Are the rationale for, and objectives of, the Systematic Review clearly stated? Partly Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Not applicable Are the conclusions drawn adequately supported by the results presented in the review? Partly If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise 25 plus years of clinical and research expertise in evaluation and management of low back pain and related disorders We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Annaswamy T and Chen A. Peer Review 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 this citation. 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