Abstract
Background: Current orthodoxy in the management of acute back pain is that GPs should refer their patients for physical therapy when it does not resolve. Guidelines from the National Institute of Clinical Excellence (NICE) state that patients with simple back pain who have not resumed their normal activities in 3 months should be referred ‘soon’ to a specialist. The evidence underpinning these recommendations was reassessed to consider the question, ‘Is there evidence to justify diverting health service resources to provide these facilities’.
Methods and results: Existing Cochrane and other systematic reviews for commonly recommended conservative treatments for acute back pain were identified through the Cochrane and DARE databases. Where available the Cochrane review was considered definitive. Reviews were identified for ‘advice to stay active’, ‘back schools’, ‘exercise’, ‘massage’, ‘multidisciplinary psychosocial rehabilitation’, ‘manipulation and ‘drug treatments’. Where reviews considered acute back pain and long-term clinical outcomes (not workloss) in studies comparing intervention with no treatment or placebo the reviewers’ conclusions were accepted. In other cases, the reviewers’ assessment of individual relevant papers was considered to be definitive. Massage was the only treatment with evidence of a clinically important long-term effect. This conclusion was based on one small study.
Conclusions: There appears to be inadequate randomised controlled trial (RCT) evidence to justify diversion of NHS resources from proven interventions to expand services for acute simple back pain. An RCT to show that an intervention for acute back pain decreases the proportion disabled at one year from 10% to 5% requires 1,250 randomised participants (a = 0.05, b=0.2). Obtaining RCT evidence to confirm or refute that these interventions will have meaningful health impact may be impossible. We need to consider other ways of obtaining evidence to inform the development of models of care for those with acute back pain.
Correspondence should be addressed to the editorial secretary: Dr Charles Pither, c/o British Orthopaedic Society, Royal College of Surgeons, 35-43 Lincoln’s Inn Fields, London WC2A 3PN.
