Acute Low Back Pain: on-line information by paul hendrick

Manual Therapy xxx (2012) 1e7

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Original article

Acute low back pain information online: An evaluation of quality, content accuracy and readability of related websites Paul A. Hendrick*, Osman H. Ahmed, Shane S. Bankier, Tze Jieh Chan, Sarah A. Crawford, Catherine R. Ryder, Lisa J. Welsh, Anthony G. Schneiders Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin 9054, New Zealand

a r t i c l e i n f o

a b s t r a c t

Article history: Received 22 June 2011 Received in revised form 20 February 2012 Accepted 24 February 2012

The internet is increasingly being used as a source of health information by the general public. Numerous websites exist that provide advice and information on the diagnosis and management of acute low back pain (ALBP), however, the accuracy and utility of this information has yet to be established. The aim of this study was to establish the quality, content and readability of online information relating to the treatment and management of ALBP. The internet was systematically searched using Google search engines from six major English-speaking countries. In addition, relevant national and international low back pain-related professional organisations were also searched. A total of 22 relevant websites was identiﬁed. The accuracy of the content of the ALBP information was established using a 13 point guide developed from international guidelines. Website quality was evaluated using the HONcode, and the Flesch-Kincaid Grade level (FKGL) was used to establish readability. The majority of websites lacked accurate information, resulting in an overall mean content accuracy score of 6.3/17. Only 3 websites had a high content accuracy score (>14/17) along with an acceptable readability score (FKGL 6e8) with the majority of websites providing information which exceeded the recommended level for the average person to comprehend. The most accurately reported category was, “Education and reassurance” (98%) while information regarding “manipulation” (50%), “massage” (9%) and “exercise” (0%) were amongst the lowest scoring categories. These results demonstrate the need for more accurate and readable internetbased ALBP information speciﬁcally centred on evidence-based guidelines. Ó 2012 Elsevier Ltd. All rights reserved.

Keywords: Acute low back pain Internet Health Information

1. Introduction The internet has become a major source of health-related information and its use is expected to increase exponentially (Sambandam et al., 2007). A recent survey found that 60% of internet users accessed the internet to ﬁnd health-related information (Atkinson et al., 2009), with factors such as convenience and accessibility cited as key reasons (McMullan, 2006). However, a lack of quality assurance relating to web-based health information potentially means that some details may be incomplete, or even incorrect, leading to misinformation that could delay recovery or even precipitate harm (Dutta-Bergman, 2003). Acute low back pain (ALBP) is one of the most common musculoskeletal disorders, in part due to its cyclic nature of remission and relapse (Kent and Keating, 2005; Krismer and van Tulder, 2007; Majid and Truumees, 2008). For most patients with

* Corresponding author. Tel.: þ64 3 479 5428; fax: þ64 3 479 8414. E-mail address: paul.hendrick@otago.ac.nz (P.A. Hendrick).

non-specific ALBP the source of symptoms is unknown. The selflimiting but frequent nature of the condition means the majority of patients do not seek specific medical attention for each episode (Majid and Truumees, 2008), but rather self-manage the condition from information sourced from the community that includes personal treatment recommendations and anecdotes (Bush et al., 1993). Thus, the internet offers a potentially important source of health education for this condition. The popularity of health information on the internet is reflected by the increasing number of studies evaluating the quality of health-related information (Starman et al., 2010; Ahmed et al., 2011). To date however, only two studies have previously evaluated the quality of online information relating to low back pain (LBP) (Li et al., 2001; Butler and Foster, 2003). These studies found that the quality of LBP information available on the internet was generally poor. Since the publication of this work nearly a decade ago, a large number of international guidelines for non-specific ALBP has been published (Dagenais et al., 2010) which has consequently resulted in a substantial increase in the available evidence for effective management of LBP. Taking into consideration the

Please cite this article in press as: Hendrick PA, et al., Acute low back pain information online: An evaluation of quality, content accuracy and readability of related websites, Manual Therapy (2012), doi:10.1016/j.math.2012.02.019

P.A. Hendrick et al. / Manual Therapy xxx (2012) 1e7

growth in the internet during the past decade and increasing access to evidence-based guidelines, there is a timely need for a review of internet sites that provide information online for the management of ALBP. It is agreed that health information needs to be current, accurate, evidence-based, and unambiguous in order to provide the end user with the most valid and reliable information (Lawrentschuk et al., 2009). Accuracy in health information is especially important for globally prevalent conditions such as ALBP, where specific information available to the public is important to promote effective self-management strategies. The purpose of this study was to compile a non-exhaustive list of current websites on GoogleÔ which contain information on the management of non-specific LBP and to evaluate the quality and content accuracy of such websites in relation to current evidence-based practice guidelines. As part of such a process, the study also aimed to evaluate the management information on selected LBP sites related to national and international bodies. A secondary aim was to examine the readability of the information and quality of the websites. The results will allow evaluation of current website management information available to the public for the management of non-specific ALBP in relation to current best-practice guidelines. 2. Methodology A cross sectional study design was chosen to evaluate the content and quality of online information on the internet related to the management of ALBP. The analysis was carried out in two stages: Firstly a comprehensive checklist was developed to evaluate content accuracy of online ALBP information and termed the, “ALBPguide”. Secondly an extensive internet search was conducted and a selection of LBP websites from recognised professional, national and international spinal/LBP organisations were examined. Website information was subsequently evaluated and scored for content accuracy and readability. 2.1. Content assessment (ALBPguide) No content analysis for web-based information for the management of non-specific ALBP currently exists and therefore the authors developed a 13 item checklist (ALBPguide) in order to assess the content of each website. Since these websites would be sourced from a number of countries it was decided to develop the ALBPguide from a synthesis of current national guidelines for nonspecific ALBP, rather than specifically look at how each website matches guidelines for the country of origin (since websites are often sourced beyond the country of origin). A recent review of all national guidelines for non-specific ALBP was therefore chosen as the review document to develop the ALBPguide (Dagenais et al., 2010). A comprehensive review of the current international guidelines (Dagenais et al., 2010) contained in the review for nonspecific ALBP management was carried out by two experienced Manipulative Physiotherapists in the research team (PH and AS). It was arbitrarily decided that management intervention components of the ALBPguide required at least half (50%) of the countries involved in recent LBP guideline publication to report on the specific management interventions. Inclusion of these management interventions in the ALBPguide required three-quarters (75%) of the international guidelines to be in agreement as to the evidence-based use of the intervention (Table 1). Two authors (PH and AS) independently evaluated each of the management interventions and through subsequent consensus reached full agreement on all interventions included in the ALBPguide. In addition, red flags detailed in the international guidelines (Dagenais et al., 2010) were evaluated by the same two authors. For

Table 1 ALBPguide. Checklist number

Description of ALBPguide management intervention

Yes/no criteriona

1 2

Encouragement to stay active within the limits of pain. Medications limited to NSAIDS, muscle relaxants, acetaminophen and opioids. Brief education and reassurance about back pain and its self-limiting nature. Manipulation. Bed rest to be advised only within the time limit of 2 e3 days. Speciﬁc back exercise. Massage. Physical modalities (ice, heat, traction, ultrasound and TENS). Acupuncture. Lumbar supports. Injections. Behavioural therapy. Surgery.

Yes Yes

3 4 5 6 7 8 9 10 11 12 13

Yes Yes Yes No No No No No No No No

a Based upon 75% agreement of management intervention across international guidelines for ALBP management.

the purpose of this research it was decided to evaluate the presence of at least 4 flags (from the evidence-based list of red flags (see appendix 1)) (Dagenais et al., 2010). While the inclusion of red flags is described in the results they are not scored in the ALBPguide as they were considered part of patient assessment rather than management. Short descriptors were created for each management item reflecting the key message from the guidelines (see Table 1). Each of the management items for ALBP was grouped into one of two categories (Dagenais et al., 2010). A “yes” category was determined by an evidence-based recommendation that a management intervention item (e.g. manipulation) should be included in clinical practice. Those items which were not supported by evidence-based recommendations were categorised as “no” (i.e. not supported in clinical practice). The scoring system for the ALBPguide is detailed in Table 2 and had a maximum score of þ17 with scores potentially ranging from 13 to þ17. Any information on a website relating to an item on the ALBPguide which was considered to be misinformation was given a score of 1, indicating the information was present but incorrect. This scoring system was modelled on the one used in a previous study on LBP internet information (Butler and Foster, 2003). 2.2. Search strategy All evaluated websites were required to be in English and be freely available to the public (i.e. not require a login, membership, or restricted registration to enter the site). It was mandatory that the content of the website included information relating to the management of ALBP. Websites were excluded if they focused on chronic LBP or general back pain information, or if the content was not specifically related to an acute onset of LBP. Journal articles, Table 2 Scoring criteria for ALBPguide. Yes (recommended clinical intervention by guidelines)

No (clinical intervention not supported by guidelines)

Score

Descriptor

Score

Descriptor

Present and complete Present but incomplete Not present Present but incorrect

1 0 1

Present and complete Not Present Present but incorrect

2 1 0 1

P.A. Hendrick et al. / Manual Therapy xxx (2012) 1e7

blogs, forums, videos, and audio links were excluded. Hyperlinks (links to other webpages) and PDFs (Portable Document Folders) that led to information within the same website were followed and included in the analyses; however hyperlinks which led to an external website were excluded.

websites assessed, two researchers (SB and SC) independently scored each of the items from the ALBPguide for websites which met the inclusion criteria. The scoring for each of the items was then compared and if a disagreement arose, a third researcher (TJC) scored the item independently and a consensus score was reached.

2.3. Google search

2.7. Analyses

The search strategy was designed to locate websites that would be easily accessible to the general public. For the purposes of this study Google was used as the primary search engine as it is internationally acknowledged as the most popular search engine accounting for up to 67% of all internet searches (Bernstam et al., 2005). A systematic search of the internet was conducted using the following search terms “acute low back pain AND treatment OR management” using the relevant Google search engine from the six major English-speaking countries: Australia (www.google.com.au), Canada (www.google.ca), New Zealand (www.google.co.nz), South Africa (www.google.co.za), United Kingdom (www.google.co.uk) and the United States of America (www.google.com). This procedure was undertaken using an advanced Google search, reporting results in English only. The search was carried out on the 3rd February 2011 using the search engines mentioned above. From these searches, the ﬁrst 10 relevant websites that met the inclusion criteria were recorded, and any repeat/duplicate websites were manually removed. In addition, websites of major national/international organisations and professional bodies involved in spinal/LBP research and management were also searched. The process involved compilation of a non-exhaustive list of relevant websites and was cross-checked by the principle researchers who are actively involved in LBP research (PH, AS, OA). Additional LBP sites related to national and international bodies which arose during the Google search stage were also included in the study.

Descriptive statistics (mean and standard deviation) were calculated for the ALBPguide, FKGL and FRES. Independent t-tests were carried out to investigate differences in ALBPguide scores for websites that were HON approved and those that were not. Pearson correlation coefﬁcients were conducted between ALBPguide and reading grade level (FKGL). Kappa values were calculated to evaluate inter-rater reliability for the each of the management interventions in the ALBPguide and an overall Kappa was calculated for the ALBPguide. Microsoft Excel 2010Ô was used to calculate descriptive statistics and Med CalcÔ was used to determine Kappa scores for inter-rater reliability.

2.4. HONcode (information quality tool) The HONcode is the most commonly used benchmark for health website quality (Peterlin et al., 2008; Morr et al., 2010) and is currently used by over 7300 websites, covering 10 million pages in 102 countries. In order for a website to be approved by the HON Foundation, it must follow the HONcode principles (listed in appendix 2). If these criteria are met, the website is awarded a HONcode logo which is displayed on the website. For the purposes of this study, the item was scored as “Yes” or” No”. 2.5. Readability assessment

3. Results After removing duplicates a total of 19 relevant websites was located from the Google search, and a further 59 websites from professional organisations was screened. Only three websites from the professional organisations contained information relating to the management of ALBP (Fig. 1), leaving a total of 22 websites to be evaluated using the ALBPguide (see Table 3). The average ALBPguide score for all websites was 6.73 points (SD ¼ 4.33), from a maximum score of 17. The highest recorded ALBPguide score was 16 out of 17 (http://besthealth.bmj.com/x/ index.html) and the lowest score was 0 out of 17 (http://www. spineuniverse.com/conditions/back-pain/low-back-pain/medicationand-treatment-acute-low-back-pain). The average scores for the FKGL were 9.37 (SD ¼ 2.92) (Table 3). There was negative correlation between FKGL and ALBPguide: r ¼ 0.39, p < 0.05 (see Fig. 1). Of the 22 websites evaluated, 68% (15/22) contained satisfactory information about red ﬂags (>4 ﬂags) and 41% (9/22) were HON-approved websites (Table 3). 3.1. Management interventions Management interventions recommended from the guidelines (“Yes” category) scored relatively highly on each of the websites. “Education and reassurance” achieved the highest overall score on the ALBPguide with 43/44 points (98%), while “manipulation” scored the lowest with 23/44 (52%) on the ALBPguide score.

The FLESCH-Kincaid Grade level (FKGL) is a widely accepted scale to evaluate readability (Paasche-Orlow et al., 2003). The FKGL calculates a reading level using the mean sentence and word length. Reading grades, produced from the United States educational school grades, range from 3 (lowest) to 12 (ﬁnal year of high school) (Williamson and Martin, 2010). Previous studies suggest health information for the general public should be ideally presented at a grade level of between 6 and 8 (Van der Marel et al., 2009). Microsoft Word 2007Ô was used to determine the FKGL for each website using the inbuilt readability statistics function. 2.6. Procedure Prior to undertaking the content assessment, three members of the research group familiarised themselves with the ALBPguide scoring system and a full internet search was then completed within a 24 h period (3/02/11). Once all duplicates had been removed and

Fig. 1. Search strategy ﬂowchart.

P.A. Hendrick et al. / Manual Therapy xxx (2012) 1e7

Table 3 ALBPguide score, readability and HONcode scoring for included websites. Website and URL

Total ALBPguide score/17

Red ﬂags HONcode Readability (presence > 4) FleschKincaid Grade Level

Best Healtha http://besthealth.bmj. com/x/index.html Accident Compensation Corporation (ACC)a http://www.acc.co.nz/ New Zealand Guidelines Group (NZGG) http://www.nzgg.org.nz/ guidelines/0072/ acc1038_col.pdf Back Pain Europe http://www. backpaineurope.org/ web/ﬁles/WG1_ Guidelines.pdf E Medicine Health http://www. emedicinehealth.com/ back_pain/article_em. htm Web MD http://www.webmd.com/ back-pain/tc/low-backpain-treatmentoverview Wikipedia http://en.wikipedia.org/ wiki/Low_back_pain Patient http://www.patient.co.uk/ health/Back-Pain.htm Physiotherapy New Zealanda http://www. physiotherapy.org.nz/ MainMenu Bupa http://www.bupa.co.uk/ individuals/healthinformation/directory/ b/backpain Family Health Guide http://www. familyhealthguide.co. uk/lower-back-pain/ treatment-and-relief. html Med Info http://www.medinfo.co. uk/conditions/ lowbackpain.html National Institute of Neurological Disorders and Stroke (NINDS) http://www.ninds.nih.gov/ disorders/backpain/ detail_backpain.htm Australian National Health and Research Council (NHRC) http://www.nhmrc.gov.au/ publications/synopses/ cp94syn.htm National Health Service http://www.nhs.uk/ Conditions/Back-pain/ Pages/Treatment.aspx

YES

5.1

YES

7.1

YES

7.9

YES

9.9

YES

10.9

YES

7.8

YES

13.0

YES

7.7

YES

7.7

Table 3 (continued ) Website and URL

Virtual Medical Centre http://www. virtualmedicalcentre. com/diseases.asp? did¼815&title¼LowerBack-Pain About.com http://orthopedics.about. com/cs/backpain/a/ backpain_2.htm Back.com http://www.back.com/ articles-back_pain_ relief.html Cure Back Pain http://www.cure-backpain.org/ Permanente Medical Group http://www.permanente. net/homepage/kaiser/ pdf/21800.pdf Medicine Net http://www.medicinenet. com/low_back_pain/ article.htm Spine Universe http://www. spineuniverse.com/ conditions/back-pain/ low-back-pain/ medication-andtreatment-acute-lowback-pain Average (SD)

Total ALBPguide score/17

Red ﬂags HONcode Readability (presence > 4) FleschKincaid Grade Level

11.4

YES

11.0

YES

8.6

YES

7.7

YES

5.7

11.5

YES

17.3

6.72 (1.21)

9.37 (2.92)

YES

9.6

YES

10.9

YES

7.8

12.3

YES

4.5

Note that all websites except for those marked with an “*” were sourced from the Google search. Asterisked websites were sourced from prior knowledge and industry sample respectively.

Management interventions which were not recommended from the guidelines (“No” category, shown in Table 2) were more variable with “bed rest” scoring the highest with a score of 14/22 (64%), while “physical agents” scored lowest with a score of 11/22 (50%) on the ALBPguide. The majority of items from the ALBPguide showed moderate to good inter-rater agreement (k ¼ 0.41e0.8) with “surgery”, “injections”, “manipulation”, “education” and “staying active” demonstrating lower levels of inter-rater reliability (Table 4). The overall Kappa value for the ALBPguide was 0.62 (CI: 0.55e0.67), demonstrating good inter-rater reliability (Altman, 1991). Examples of misinformation regarding ALBP management interventions were taken directly from the websites and are detailed in Table 5.

4. Discussion

YES

10.8

The internet is increasingly used by the general public as an easily accessible source of health-related information. The results from this study demonstrate that ALBP management information currently available on the internet is not uniformly consistent with existing international guidelines. Information on “general advice and reassurance” was the most consistent and accurate information across all selected websites, resulting in the highest score on the ALBPguide. Most websites also provided accurate information on the beneﬁts of staying active, with the majority achieving the full

P.A. Hendrick et al. / Manual Therapy xxx (2012) 1e7 Table 4 Inter-rater reliability of the ALBPguide. ALBPguide item # and topic

Kappa score (k) (95%CI)

Strength of agreement

1. Stay active 2. Bed rest 3. Education 4. Back exercises 5. Medication 6. Massage 7. Manipulation 8. Physical agents 9. Acupuncture 10. Lumbar support 11. Injection 12. Behavioural Therapy 13. Surgery Overall

0.22 0.69 0.10 0.59 0.46 0.66 0.29 0.48 0.62 0.66 0.24 0.62 0.09 0.62

Fair Good Poor Moderate Moderate Good Fair Moderate Good Good Fair Good Poor Good

( 0.15 to 0.60) (0.38e1.00) ( 0.16 to 0.37) (0.31e0.86) (0.16e0.77) (0.34e0.98) (0.02e0.57) (0.19e0.78) (0.31e0.94) (0.33e1.00) ( 0.26 to 0.76) (0.16e1.00) ( 0.19 to 0.37) (0.55 to 0.69)

score for this item. Of particular concern was that most websites scored less than half of the total maximum score (17) on the ALBPguide which may in part be explained by the indeﬁnite wording of management recommendations encountered on many websites. Internet information scored poorly when management interventions shown to be non-efﬁcacious in the guidelines were

Table 5 Examples of website misinformation relating to management interventions. Name of website

Recommendations from ALBPguide

Quote of incorrect information

“As soon as possible following trauma, patients should apply a cold pack or a cold compress (such as a bag of ice or bag of frozen vegetables wrapped in a towel) to the tender spot several times a day for up to 20 min.” Measures that are effective Australian National for relieving acute low back Health and Research pain are: staying active Council (NHRC) (relieves pain better than resting in bed), having written information (it is helpful to discuss written information with your health practitioner) and heat wrap therapy.” Back.com (Acute Back Lumbar supports “Use a cervical roll (a foam roll Pain) are not indicated. approximately 3 inches in diameter and 18 inches long) to support the natural curves in your neck or low back.” Cure Back Pain Acupuncture is not “For short term relief from indicated. acute back pain, acupuncture is highly recommended” Medicine.net Massage is not indicated. “The treatment of lumbar No physical modalities strain consists of resting the (heat, cold and back (to avoid re-injury), electrotherapy) are medications to relieve pain indicated. and muscle spasm, local heat applications, massage, and eventual (after the acute episode resolves) reconditioning exercises to strengthen the low back and abdominal muscles.” Spine Universe Massage is not indicated. “Considering that many cases of back pain are caused by muscle strain and overuse, its wonderful news that massage is a worthwhile treatment option.” National Institute of Neurological Disorders and Stroke (NINDS)

No physical modalities (heat, cold and electrotherapy) are indicated.

described using words such as ‘may work’ or ‘works for some patients’. Information retaining to physical modalities had the lowest overall ALBPguide category score with many websites suggesting that both heat and ice were an effective treatment for ALBP. This recommendation may be due to the historical and continuing use of ice and heat by the general public, and the fact that these physical modalities are readily available and commonly used by some health professionals in combination with other forms of treatment (French et al., 2006). Information regarding manipulation as a management intervention for ALBP was not consistent across the websites. Manipulation was specifically mentioned in 15 of the 22 websites; seven of which contained “present and complete” information. Encouragingly no websites were found to contain misinformation regarding manipulation. Website advice on medication use scored relatively highly, however many of the websites did not include complete information for all listed medications and several websites suggested “over the counter drugs” for ALBP management (which may be due to differing drug prescription policies across countries) (Kennedy, 1996). Encouragingly, 69% of websites included information on four or more red flags from the international guidelines (Dagenais et al., 2010). While red flags are not a management intervention and their prevalence in ALBP sufferers is low (0.9%) (Henschke et al., 2009), their inclusion in the current study was intended to acknowledge important safety issues related to the differential diagnosis of non-specific ALBP (especially for the assessment of more severe pathologies). It is acknowledged that assessment of internet-based health information is important (Hanif et al., 2009). The strength of the ALBPguide developed for this study is that it represents a synthesis of guideline evidence to analyse and appropriately grade the quality of internet-based information. This ALBPguide classified interventions categorically based upon their recommendation (Yes/ No) as a management intervention, whereas previous scoring systems employed to assess LBP quality on the internet focused only on the quality of information related solely to interventions recommended at that time for the management of ALBP (Butler and Foster, 2003). The ALBPguide had good overall inter-reliability (k ¼ 0.62), however some variation was found across management interventions (k range 0.09e0.69). Further studies are needed to validate the ALBPguide against other measures of information quality assessment in LBP. The quality of the website information showed that 41% of websites were HON approved; a figure which is slightly higher than those assessed in a recent study of health-related websites (Starman et al., 2010). Our study found no difference (p ¼ 0.35) in the ALBPguide scores between websites that were HON approved and those that were not HON approved. This reinforces the fact that the HONcode does not necessarily reflect the accuracy or quality of the information on the website (Peterlin et al., 2008), but serves as a mechanism to help readers understand the purpose and source of the information. It is also acknowledged that website information is only useful to a patient if it is readable (Oermann and Wilson, 2000; Berland et al., 2001). The readability scores in our study indicate that a large proportion of ALBP website information may be too complex for mainstream users to understand (Bernstam et al., 2005), and this assertion is further supported by recent evidence that 25% of the American population that have an education below high school level use the internet to access health information (Fox and Jones, 2009). Inconsistencies in online information regarding management interventions for ALBP may be as a result of differences in guideline specification (Murphy et al., 2006). Primarily, this is due to the differing methods of assessing and weighting research evidence for

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guidelines between countries. Adoptions of guidelines remain inconsistent across countries (Armstrong et al., 2003; Strand et al., 2005; Fullen et al., 2007) and these results are further reflected in the website findings, whereby current practice is not necessarily guideline based. With global access to the internet, the development of consensus-based international guidelines for the management ALBP would help standardise best practice, however the optimal utilisation of guidelines by clinicians needs further investigation. The number of websites from national and International spinal organisations carrying information relating to the management of ALBP was surprisingly low. One reason for this may be that such websites are designed primarily for practicing clinicians and researchers, and they are linked directly to the guidelines for the country which the organisation represents. It could be argued however that current, updated evidence-based guidelines for the assessment and management of ALBP would be a useful resource for clinicians and researchers, and potentially a valuable and trusted resource for patients. 4.1. Recommendations for future research The internet is continually evolving, as are clinical practice guidelines for ALBP (Sandvik, 1999). Future studies should focus on how patients retrieve information relating to management information for ALBP on the internet, the potential search terms that patients might employ for this and, the varying and often diverse sources of such information (i.e. videos, sites such as YouTube/ Facebook/Twitter, blogs). Also, evaluation of the quality of acute low back pain management information from all sources should be extensively reviewed for both quality and readability. Although the use of internet-based education in LBP has not been studied in detail, empowering patients with current guideline based advice via a simple “back book” has been shown to be clinically efficacious in various LBP groups (Burton et al., 1999; Udermann et al., 2004; Coudeyre et al., 2007). A recent study also demonstrated that guideline based care was responsible for both improvements in physical functioning and for a lower utilisation of care (Rutten et al., 2010). The continued growth of the World Wide Web in modern society necessitates further research on the potential role for internet-based information on clinical outcomes. 4.2. Limitations This study represented a non-exhaustive search of websites readily available to the general public. Although Google was the only search engine used, recent statistics show that Google is the leading search engine worldwide and used for over 67% of all searches on the internet (Hitwise, 2011). A potential limitation is that only the first 10 relevant “hits” were taken from each Google search, a decision based on evidence indicating that the majority of people only look at the first page of hits when searching with a search engine (Atkinson et al., 2009). The authors also recognise that the grouping and scoring of the management interventions employed in this study was a pragmatic choice based upon a consensus amalgamation of current national guidelines, and therefore further validation is required in future study’s to assess the use of this process to determine content quality of website information pertaining to LBP management. Retrieval of relevant websites may also have been limited from a global perspective by limiting Google searches to English-speaking countries only. 5. Conclusion The internet represents a crucial but under-researched source of information for patients with back pain. Internet-based information

available to the public which relates to evidence-based management of non-specific low back pain is currently limited, and readability of such content is often too difficult for some people to interpret and understand. Development of future low back pain websites should be in accordance with evidence-based guidelines, better targeted for the general public and, written at an appropriate level to ensure the availability of reliable and understandable information. Appendix 1 Red flags. Age < 20 Age > 50 Fecal incontinence Fever Gait abnormality History of cancer Immune suppression Intravenous drug use Night pain No response to care Osteoporosis

Pain at multiple sites Saddle numbness Steroid use Structural deformity Systemic unwellness Trauma Unexplained weight loss Urinary retention Weakness in limbs Widespread neurological symptoms

Appendix 2 The HONcode principles.a Principles

Description

1 2 3 4 5 6 7 8

e e e e e e e e

Table adapted from the HON website (www.hon.ch).

Authority Complementarity Conﬁdentiality Attribution Justiﬁability Transparency Financial disclosure Advertising

Give qualiﬁcations of authors Respect the privacy of site users Respect the privacy of site users Cite the sources and dates of medical information Justiﬁcation of claims/balanced and objective claims Accessibility, provide valid contact details Provide details of funding Clearly distinguish advertising from editorial content

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