The evidence base for managing older persons with low back pain

It has been suggested that older persons are less likely to receive optimal care for pain, and a recent population study suggested that management of low back pain (LBP) in primary care differed with older age. Low back pain is the most commonly reported regional pain syndrome, and the objective of the current review was to determine the evidence base for managing LBP in older persons; specifically, to ascertain if randomized controlled trials provide information on the effectiveness of two common non-pharmacological treatments (manual therapy, physical activity/exercise) for LBP amongst older patients. We examine data from trials which contributed to the United Kingdom National Institute for Health and Clinical Excellence (NICE) guidelines on the management of LBP and determine whether the trials had upper age restrictions, their justification and whether any age-specific analyses had been conducted. The present survey included 21 studies of manual therapy and 71 of physical activity/exercise. Many studies had an upper age limit of ≤ 60 years (24% manual therapy, 44% physical activity/exercise) or 61-70 years (33%, 41%) but few gave a rationale for imposing an upper age limit in the trial eligibility criteria (2 out of 17 studies of manual therapy, 4 out of 68 studies of physical activity/exercise). Only 14% of studies of manual therapy and 1% of physical activity/exercise studies provided an age-specific analysis. Upper age limits in back pain trials of manual therapy and physical activity/exercise are common but a justification for these is rarely given. Almost no studies have reported whether effectiveness differs by age.