Usual Care for Low-Back Pain Often Inconsistent With Guidelines

By Will Boggs MD

January 02, 2020

NEW YORK (Reuters Health) - Usual care for patients with low-back pain in family practice and emergency departments is often inconsistent with clinical-practice guidelines, according to a systematic review.

"I wasn't especially surprised by most of the findings, but I was interested in the low rates of education and reassurance delivered to these patients," Dr. Steven J. Kamper of the Faculty of Medicine and Health, University of Sydney, in Camperdown, Australia, told Reuters Health by email.

International guidelines for treating patients with low-back pain include advice to remain active, education and reassurance. Adjunctive treatment options include application of heat, manual therapy, nonsteroidal anti-inflammatory drugs (NSAIDs) and structured exercise, and cognitive-behavioral therapy for patients with persistent symptoms.

Imaging is discouraged unless serious spinal pathology is suspected, and strong analgesics, including opioids, should be prescribed with caution and only in selected patients.

Dr. Kamper's team described the assessments, treatment advice, imaging, medication, and referrals provided in family practice or emergency departments to patients with low-back pain in their systematic review of 26 studies that included a total of more than 194,000 patients.

There were no high-quality estimates of rates for assessment of red flags, history taking, physical examination, or neurological examination, the researchers report in Pain.

Two high-quality studies in family-practice settings reported that 21% and 23% of patients received education or reassurance, and one study reported that 19% of patients received exercise advice.

There were no high-quality estimates for advice regarding bedrest or return to work and no high-quality estimates for any of these types of advice in emergency departments.

A significant fraction of patients received referral for X-ray (16% to 20% from family practice, 30% from emergency departments), and as many as 6% of patients in both settings were referred for CT scans. MRI or CT was performed in 10% of family-practice patients and 7% to 18% of emergency-department patients.

While NSAIDs were recommended to 36% to 37% of family-practice patients and 50% of ED patients, opioids (including in combination with other analgesics) were prescribed to 5% to 31% of family-practice patients and as many as 61% of emergency department patients.

Physiotherapy referrals were common (14% to 27% of family-practice patients), and 8% to 10% of patients were referred for surgical consult.

"The findings point to both overuse and underuse of medical services including imaging, medication prescription, and provision of advice in the usual care of people with low back pain," the authors conclude. "The findings also highlight the need for health systems to invest in and maintain data collection infrastructure."

"What struck me is the poverty of data available to answer this pretty simple question" of what type of care low-back patients receive, Dr. Kamper said. "How is it that it is difficult to find out what happens to this very large patient group when they access care? Data capture and availability in health systems are like something from the middle ages. This holds back understanding of what is happening to patients and impedes improvements to quality of care and system efficiency."

Dr. Stephanie Mathieson of The University of Sydney, who was not involved in the study but has evaluated different treatments for low-back pain, told Reuters Health by email, "It was surprising to read that there were no high-quality estimates of advice provided within the emergency department (ED) setting. It is unlikely that people with low-back pain admitted to ED do not receive any advice and more likely to be a reflection of underreporting in this setting."

"Patient awareness and acceptance of advice as being a legitimate form of management for back pain are needed, as well as managing patient expectation as to the type of treatment being provided, such as prescribing a medicine," she said. "Clinicians can be time-poor, which is a barrier to routinely delivering advice to patients with low-back pain. Future research could invest in developing strategies to assist overcoming this obstacle."

Dr. Mathieson added, "It was not surprising that the prescription and use of opioid analgesics differed between the family practice and ED setting. The care patients with low-back pain seek can depend on the accessibility, availability, and urgency of a medical consultation. Patients may present to ED 'after-hours' or when in extreme pain rather than making an appointment with a family physician. The use of opioid analgesics in ED (61%) was double what was prescribed by family physicians (31%). This may be appropriate prescribing in these individual settings. Future research is needed to explore opioid use following ED presentation and the continuum of care bridging treatment from family physicians."

Dr. Alan D. Kaye of Louisiana State University School of Medicine, in Shreveport, and Tulane School of Medicine, in New Orleans, who recently reviewed the pathophysiology, diagnosis, and treatment of low-back pain, told Reuters Health by email, "The opioid epidemic is very real, with 75,000 deaths a year in the U.S. Healthcare workers need to be part of the solution, not part of the problem. Acute low-back pain usually resolves and in most cases does not need opioids or imaging."

"What needs to be done is stronger education much like the newer requirements with approved continuing medical education for opioid prescribers throughout the country," said Dr. Kaye, who was not involved in the review. "This education should be implemented in training as well."

SOURCE: Pain, online November 14, 2019.