The RCGP - Clinical and Special Projects, Clinical Guidelines, Acute Low Back Pain. Contents, Index page


Guideline Development Process
Evidence Review Methods
Evidence Ratings

Evidence Ratings

The evidence is rated on a three star system. Therapies are judged on randomised controlled trials (RCTs). Wherever possible, references are to systematic reviews or to key RCTs. However, RCTs are not applicable to some important areas such as assessment, epidemiology and natural history, and complications of treatment. There, the evidence is mainly from prospective cohort studies of acute low back pain in primary care.

The weight of evidence is rated:
Generally consistent finding in a majority of multiple acceptable studies.
Either based on a single acceptable study,
or a weak or inconsistent finding in some of multiple acceptable studies.
Limited scientific evidence, which does not meet all the criteria of acceptable studies.

'Acceptable' studies of therapy: 'Acceptable' studies of assessment & natural history:
randomised controlled trial
acute (<3/12) or recurrent LBP
relevant to primary care
at least 10 patients in each group
patient centred outcome(s).
prospective cohort study
acute or recurrent LBP
relevant to primary care
at least 100 patients
at least 1 year follow up.

The present conclusions and the three star ratings are based on the evidence which is now available.

Where the conclusions are unchanged from AHCPR, they are printed like this in italics.

The original AHCPR ratings are then also shown in brackets for comparison and to show how the present ratings were devised. AHCPR applied this grading very strictly and did not rate any evidence on acute back pain better than B.

The original AHCPR (1994) ratings are:
  1. Strong research-based evidence (multiple relevant and high-quality scientific studies).
  2. Moderate research-based evidence (one relevant high-quality scientific study or multiple adequate scientific studies).
  3. Limited research-based evidence (at least one adequate scientific study in patients with low back pain).
  4. Panel interpretation of information that did not meet inclusion criteria as research-based evidence.

The group decided to rely on the rating of the evidence. There is now general agreement on methods of rating. There is also growing international agreement of the conclusions which can be drawn from the evidence on the management of acute back pain. We did not attempt to rate the recommendations separately, because of problems of interpretation and lack of agreed methodology.

The detailed evidence from the reviews and other acceptable studies is presented in Chapter 2, under headings of:

  • Assessment
  • Management
    • symptomatic measures
    • therapies
  • Interventions of little or no benefit.

This guideline and evidence review is concerned with the clinical management of acute low back pain. For epidemiological and economic reviews then the works by Evans & Richards (1996), CSAG (1994b), Croft (1996) and Klaber Moffett (1995) are suggested.

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