Clinical Review Evidence based case report

Low back pain: which is the best way forward?

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7191.1122 (Published 24 April 1999) Cite this as: BMJ 1999;318:1122
  1. Ash Samanta, consultant rheumatologist,
  2. Jo Beardsley, research assistant
  1. Department of Rheumatology, Leicester Royal Infirmary NHS Trust, Leicester LE1 5WW
  1. Correspondence to: Dr Samanta
  • Accepted 18 January 1999

Mr A, a fit and healthy 62 year old, presented with a 10 year history of intermittent non-specific low back pain. He had been able to control his symptoms with several self help measures, including weight control, regular aerobic activity, a firm mattress, back mobilisation exercises, and a naturally positive attitude. He had an active lifestyle and travelled extensively, but his episodes of acute pain had become increasingly severe and frequent and were starting to interfere with his quality of life. Radiological examination showed degenerative changes in the lumbar spine, predominantly at L4 and L5. A review of Mr A's medical history and a clinical examination did not give rise to any suspicion that he might have a serious spinal abnormality or nerve root problems.

The clinical question

We considered the following clinical question. Which of the treatments available locally showed the best evidence of limiting acute attacks of low back pain in a patient with a history of chronic back pain?Our specific aim in Mr A's case was to obtain reliable information as quickly as possible so that we could immediately advise him of the best treatment option.

The search

Our previous experience of reviewing published reports on chronic low back pain had shown that there are many types of treatment, both complementary and conventional. Since our experience is with conventional treatments, we confined our search to these. Four main treatments available locally were relevant to Mr A's condition: physiotherapy and exercise programmes; spinal manipulation; spinal steroid injections; and transcutaneous electrical nerve stimulation. We decided to research the evidence for these treatments and to look for any other evidence based treatments that might be relevant.

Previous searching of Medline and Embase had shown a profusion of reports on treating low back pain. On closer examination, however, many of these lacked …

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