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Clinical course of patients with low back pain following an emergency department presentation: a systematic review and meta-analysis
  1. Danielle M Coombs1,2,3,
  2. Gustavo C Machado1,2,
  3. Bethan Richards1,4,
  4. Crystian B Oliveira5,
  5. Robert D Herbert6,
  6. Chris G Maher1,2
  1. 1 Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
  2. 2 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
  3. 3 Physiotherapy Department, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
  4. 4 Rheumatology Department, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
  5. 5 Faculdade de Ciências e Tecnologia, Universidade Estadual Paulista, Presidente Prudente, São Paulo, Brazil
  6. 6 Neuroscience Research Australia (NEURA), Sydney, New South Wales, Australia
  1. Correspondence to Ms Danielle M Coombs, PO Box M179, Missenden Road, Camperdown, New South Wales, Australia; danielle.coombs{at}


Introduction Low back pain, and especially non-specific low back pain, is a common cause of presentation to the emergency department (ED). Although these patients typically report relatively high pain intensity, the clinical course of their pain and disability remains unclear. Our objective was to review the literature and describe the clinical course of non-specific low back pain after an ED visit.

Methods Electronic searches were conducted using MEDLINE, CINAHL and EMBASE from inception to March 2019. We screened for cohort studies or randomised trials investigating pain or disability in patients with non-specific low back pain presenting to EDs. We excluded studies that enrolled participants with minimal pain or disability scores at baseline. Two reviewers independently screened the full texts, extracted the data and assessed risk of bias and quality of evidence. Estimates of pain and disability were converted to a common 0–100 scale. We estimated pooled means and 95% CIs of pain and disability as a function of time since ED presentation.

Results Eight studies (nine publications) with a total of 1994 patients provided moderate overall quality evidence of the expected clinical course of low back pain after an ED visit. Seven of the eight studies were assessed to have a low risk of bias. At the time of the ED presentation, the pooled estimate of the mean pain score on a 0–100 scale was 71.0 (95% CI 64.2–77.9). This reduced to 46.1 (95% CI 37.2–55.0) after 1 day, 41.8 (95% CI 34.7 to 49.0) after 1 week and 13.5 (95% CI 5.8–21.3) after 26 weeks. The course of disability followed a similar pattern.

Conclusions Patients presenting to EDs with non-specific low back pain experience rapid reductions in pain intensity, but on average symptoms persisted 6 months later. This review can be used to educate patients so they can have realistic expectations of their recovery.

  • musculo-skeletal
  • spine non trauma

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  • Handling editor Edward Carlton

  • Twitter @gustavocmachado, @crystianbso

  • Contributors All authors contributed substantially to conception and design, acquisition and interpretation of the data. CBO conducted the first search and initial screening of abstracts. CBO and DMC performed screening of full text determined inclusion and the main data collection. RDH, GCM and DMC performed the statistical analysis. BR and DMC provided clinical expertise in low back pain management. Study supervision was conducted by CGM and GCM. DMC drafted the manuscript. All authors participated substantially in the critical revision of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests CGM is supported by a Principal Research Fellowship from Australia’s National Health and Medical Research Council (APP1103022) as well as a Program grant (APP1113532) and two Centre for Research Excellence grants (APP1134856, APP1171459). He has received research grants from various government and not for profit agencies. His expenses have been covered by professional associations hosting conferences he has spoken at. GCM is supported by an Early Career Fellowship from Australia’s National Health and Medical Research Council (APP1141272). FlexEze provided heat wraps at no cost for the SHaPED trial that DMC, GCM, BR and CGM are investigators on.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.