Advice for the management of low back pain: A systematic review of randomised controlled trials

SD Liddle, JH Gracey, GD Baxter

Research output: Non-textual formWeb publication/site


CRD summaryThe authors concluded that advice to stay active was sufficient for acute low back pain, but patients with chronic low back pain required advice to stay active plus specific advice about relevant exercise. The absence of an adequate synthesis of the included studies means it is not possible to assess the evidence or the reliability of the authors’ conclusions. Authors' objectivesTo evaluate the effectiveness of advice for patients with acute, sub-acute and chronic low back pain.SearchingMEDLINE, PubMed, AMED, CINAHL, PsycINFO and the Cochrane Library (including DARE and the Cochrane CENTRAL Register) were searched from 1985 to September 2004; the search terms were reported. In addition, reference lists of included studies, relevant journals, reviews and meta-analyses were screened and citations tracked. Studies were excluded if they were reported only as abstracts.Study selectionStudy designs of evaluations included in the reviewRandomised controlled trials (RCTs) that were classified as high or medium quality, and had at least 10 patients per treatment group, were eligible for inclusion in the review. Studies using alternate allocation were excluded.Specific interventions included in the reviewStudies that evaluated interventions that included advice and/or patient education were eligible for inclusion. The included studies evaluated advice alone and advice in conjunction with a variety of different interventions (including exercise, ‘the Back Book’, general practitioner advice, Back School, bed rest, functional restoration programme, manipulation, massage, stretching and motivation), either alone or in combination. Control interventions included advice plus booklets or leaflets, advice only, analgesics, bed rest, usual care, versions of Back School, intensive physical training, exercise, sham exercise and behavioural treatment.Participants included in the reviewStudies of symptomatic patients with acute (less than four weeks), sub-acute (four to 12 weeks) and chronic (more than 12 weeks) low back pain were eligible for inclusion. Studies of patients with possible serious spinal pathology, spinal surgery in the previous year or fibromyalgia were excluded. Studies had to report sufficient information on the category of low back pain and report results separately for the different phases of low back pain. Male and female patients in the included studies were aged from 16 to 79 years. Outcomes assessed in the reviewInclusion criteria were not specified in terms of the outcomes. The recommended review outcomes were back-specific function (Roland-Morris/Oswestry Disability Questionnaire), generic health status (Short-Form 36/EuroQol Questionnaire), pain (frequency and severity of low back pain/ Body Pain Scale of the Short-Form 36), work disability and patient satisfaction (Patient Satisfaction Scale/Global question). Outcomes assessed using the McGill Pain Questionnaire, Aberdeen Back Pain Scale, Sickness Impact Profile and Waddell Disability Index were also acceptable. Studies that included non recommended outcomes were also included. The review also assessed adverse effects.How were decisions on the relevance of primary studies made?Two reviewers independently selected the studies and resolved any disagreements by consensus.Assessment of study qualityValidity was assessed using items for internal validity, quality of description and quality of statistical analysis (the items were specified in the review). Studies that met at least 50% of the validity criteria were classified as high or medium quality. High- and medium-quality studies were also assessed for five Cochrane Guidelines criteria: allocation concealment, drop-out rate, blinding of the patients and outcome assessor, and intention-to-treat analysis. The authors did not state how many reviewers performed the validity assessment.Data extractionTwo reviewers independently extracted the data using standardised forms and resolved any disagreements by consensus. Interventions in which there was a significant post-treatment difference (p
Original languageEnglish
PublisherUniversity of York
Publication statusPublished (in print/issue) - 30 Sept 2008


  • Advice
  • Low back pain
  • Randomised controlled trials
  • Outcome measures


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