Interventions

Information from the existing draft was updated with information from Clinical Evidence and relevant articles located and appraised independently by two reviewers according to the following inclusion and exclusion criteria. In cases where no evidence was available on interventions specifically for acute low back pain, studies containing mixed populations (acute and chronic low back pain) were considered in the review:

Inclusion criteria

Systematic reviews, randomised controlled trials Adults

Articles describing cost effectiveness of interventions

Exclusion criteria

Chronic pain

Low back pain associated with pregnancy, neuropathic pain, somatic referred pain, visceral referred pain, radicular pain, loin and gluteal pain, osteoarthritis, sciatica, degenerative joint and disc disease, aortic aneurysm, pelvic disease, retroperitoneal disease, Paget's disease, hyperparathyroidism, osteomyelitis, infection, neoplasm, fracture, ankylosing spondylitis Primary prevention of low back pain

methodological filters were used. There were no hand searches conducted.

Searches for information on diagnosis and prognosis of low back pain were conducted from the years 1998 to 2002 taking into account the date when the original guidelines were developed.

Searches for articles on interventions were conducted for the years 2001 to 2002, taking into account the search date (October 2001) used in the Clinical Evidence text (2002).

Additional articles not identified by the database search, those located in the reference lists of retrieved articles and other articles identified by content experts were also submitted to the appraisal process.

The following databases were searched in August 2002:

• PubMed (Clinical Q ueries)

• EMBASE — Physical and Rehabilitation Medicine

• The Cochrane Library, 2002, Issue 2

Access to CHIROLARS/MANTIS and PEDro was unavailable for this review.

Search Terms

• Pain assessment

• Clinical trial

• Controlled trial

• Randomised

• Systematic review .tw

Research Agenda for Acute Low Back Pain

Research should be aimed at optimising the uptake of evidence-based guidelines by clinicians and consumers.

All new interventions for acute low back pain need to be tested in well-designed randomised controlled trials (RCT) with 'advice to avoid bed rest and maintain usual activities' as the appropriate comparator.

This review identified the need for research on the following interventions, testing them in well-designed RCTs with 'advice to avoid bed rest and maintain usual activities' as the appropriate comparator:

• Temperature treatments, ice, heat

• Topical NSAIDs

• Head to head comparator trials between Cox-2 NSAIDs, traditional NSAIDs, paracetamol and opioid analgesics, and between these medications and placebo for acute low back pain

• McKenzie therapy and other specific physical regimens

• Multi-disciplinary treatment (e.g. non-occupational settings, programmatic approaches to delivering multi-disciplinary care)

• Counselling and cognitive behavioural therapy

Spinal manipulation (with and without prior xray)

• Massage (and placebo-controlled trials of massage therapy as mono-therapy and in combination with other modalities)

• TENS in patients not responding to early advice to resume normal activities

• Optimum combinations of therapies

International standardisation of definitions of intervention strategies and consistent outcome measures is strongly recommended.

Intervention studies addressing clinical and psychosocial predictors should be conducted early in the subacute phase with adequate follow up to assess for prevention of chronicity.

Further research into secondary prevention of low back pain. Cost effectiveness analysis and evidence of harm should be incorporated into future intervention studies for acute and subacute low back pain.

Summary of Key Messages: Acute Pain Management
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