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Oliveira CB, Amorim HE, Coombs DM, et al. Emergency department interventions for adult patients with low back pain: a systematic review of randomised controlled trials. Emerg Med J. 2020 Oct 9. pii: emermed-2020-209588. doi: 10.1136/emermed-2020-209588. (Systematic review)
Abstract

BACKGROUND: Most low back pain trials have limited applicability to the emergency department (ED) because they provide treatment and measure outcomes after discharge from the ED. We investigated the efficacy and safety of pharmacological and non-pharmacological interventions delivered in the ED to patients with non-specific low back pain and/or sciatica on patient-relevant outcomes measured during the emergency visit.

METHODS: Literature searches were performed in MEDLINE, EMBASE and CINAHL from inception to week 1 February 2020. We included all randomised controlled trials investigating adult patients (=18 years) with non-specific low back pain and/or sciatica presenting to ED. The primary outcome of interest was pain intensity. Two reviewers independently screened the full texts, extracted the data and assessed risk of bias of each trial using the Physiotherapy Evidence Database (PEDro) scale. The overall quality of evidence, or certainty, provided by a set of trials evaluating the same treatment was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which considers imprecision, inconsistency, indirectness and bias in the evidence.

RESULTS: Fifteen trials (1802 participants) were included with 12 of 15 at low risk of bias (ie, PEDro score >6). Based on results from individual trials and moderate quality evidence, ketoprofen gel was more effective than placebo for non-specific low back pain at 30 min (mean difference (MD) -15.0, 95% confidence interval (CI) -21.0 to -9.0). For those with sciatica (moderate quality evidence), intravenous paracetamol (acetaminophen) (MD -15.7, 95% CI -19.8 to -11.6) and intravenous morphine (MD -11.4, 95% CI -21.6 to -1.2) were both superior to placebo at 30 min. Based on moderate quality of evidence, corticosteroids showed no benefits against placebo at emergency discharge for non-specific low back pain (MD 9.0, 95% CI -0.71 to 18.7) or sciatica (MD -6.8, 95% CI -24.2 to 10.6). There were conflicting results from trials comparing different pharmacological options (moderate quality evidence) or investigating non-pharmacological treatments (low quality evidence).

CONCLUSION: Ketoprofen gel for non-specific low back pain and intravenous paracetamol or morphine for sciatica were superior to placebo, whereas corticosteroids were ineffective for both conditions. There was conflicting evidence for comparisons of different pharmacological options and those involving non-pharmacological treatments. Additional trials measuring important patient-related outcomes to EDs are needed.

Ratings
Discipline Area Score
Physician 5 / 7
Rehab Clinician (OT/PT) 5 / 7
Comments from MORE raters

Physician rater

In the setting of opiate addiction stemming from prescription opiates which continues to spiral, a review that appears to give credibility to the use of morphine for patients presenting to EDs with LBP has to be viewed skeptically as far as its focus and methodology is concerned. The abstract concludes that more trials are needed to evaluate long term outcomes of the identified choices. However, we know very well what those outcomes are for opioids and we do NOT need more trials on this!

Physician rater

The main aim was too large (all randomised intervention trials in the ED) so heterogeneity was inevitable. Often conclusions are based on only one study.

Physician rater

This review highlights the lack of evidence for ED based therapies for patients with back pain. Topical NSAIDS are probably a reasonable first line choice for many such patients, with evidence to support their use.

Rehab Clinician (OT/PT) rater

This well summarized piece of work is useful for those using Pharma in the management of low back pain and sciatica.
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