What Is Usual Care for Low Back Pain? 

A Systematic Review of Health Care Provided to Patients With Low Back Pain in Family Practice and Emergency Departments

Steven J. Kamper; Gabrielle Logan; Bethan Copsey; Jacqueline Thompson; Gustavo C. Machado; Christina Abdel-Shaheed; Christopher M. Williams; Christopher G. Maher; Amanda M. Hall

Disclosures

Pain. 2020;161(4):694-702. 

In This Article

Abstract and Introduction

Abstract

International clinical practice guidelines for low back pain (LBP) contain consistent recommendations including universal provision of information and advice to remain active, discouraging routine referral for imaging, and limited prescription of opioids. This systematic review describes usual care provided by first-contact physicians to patients with LBP. Studies that reported the assessments and care provided to people with LBP in family practice and emergency departments (EDs) from January 2000 to May 2019 were identified by searches of PubMed, EMBASE, and CINAHL. Study quality was assessed with reference to representativeness of samples, potential misclassification of patients, potential misclassification of outcomes, inconsistent data and precision of the estimate, and the findings of high-quality studies were prioritized in the data synthesis. We included 26 studies that reported data from almost 195,000 patients: 18 from family practice, and 8 from EDs. Less than 20% of patients with LBP received evidence-based information and advice from their family practitioner. Around 1 in 4 patients with LBP received referral for imaging in family practice and 1 in 3 in EDs. Up to 30% of patients with LBP were prescribed opioids in family practice and up to 60% in EDs. Large numbers of patients who saw a physician for LBP received care that is inconsistent with evidence-based clinical practice guidelines. Usual care included overuse of imaging and opioid prescription and underuse of advice and information. Suboptimal care may contribute to the massive burden of the condition worldwide.

Introduction

Low back pain (LBP) is an extremely common condition with a mean lifetime prevalence of around 40%[22] and is the leading cause of disability globally.[52] At an individual level, LBP causes limitations to day to day function, impacts mental health, can result in financial hardship, and reduces quality of life.[18] The condition also has considerable implications for society as a whole due to the costs of health care, reduced work productivity, early retirement, and strains on the welfare system.[19,48]

Recently updated clinical practice guidelines for LBP from Canada, the United States, and the United Kingdom provide some consistent recommendations for how to assess and treat patients with LBP.[2,30] Reviews of international guidelines show that these recommendations have been largely unchanged since 2000, the only major change being removal of paracetamol as first-line care[2,27] after a large RCT and subsequent systematic review published in 2015.[32,54] These guidelines are based on high-quality evidence and widely endorsed by professional organisations. Recommended assessment involves diagnostic triage[3,51] based on patient history and physical examination to exclude patients with a problem beyond the lumbar spine (eg, renal colic) and then categorise patients into 1 of 3 groups: (A) nonspecific LBP, (B) lumbar radicular syndromes (sciatica and canal stenosis), or (C) a serious pathology affecting the lumbar spine (eg, infection, fracture, and cancer). In family practice and emergency departments (EDs), more than 90% of lumbar spine problems fall into category A or B.[20,50] There is a perception that people with back pain who present to ED have on average more severe symptoms and are more likely present with serious pathology;[12] however, there are few data available to confirm this suspicion. Recommended first-line treatment for patients with LBP includes the following: advice to remain active, and education and reassurance. Adjunctive options include application of heat, manual therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and structured exercise and cognitive behavioural therapy for patients with persistent symptoms.[40] Guidelines recommend against imaging unless serious spinal pathology is suspected, and strong analgesics such as opioids should only be prescribed with caution in selected patients.

Although these recommendations are well established over several years, and health providers report being aware of them,[42,53] there are concerns about substantial gaps between guideline recommendations and the care delivered in usual practice.[15] Individual studies report high rates of imaging,[11] opioid prescription,[9] and inconsistent provision of appropriate advice. However, to date, there has been no synthesis of studies that comprehensively report the nature of usual care as delivered by primary-contact physicians for this condition. Understanding the nature of usual care in various settings is necessary to identify what aspects of care are most commonly divergent from recommendations and hence direct efforts to increase provision of evidence-based care. To address this gap, we conducted a systematic review of studies that report usual care provided by first-contact physicians, the extent to which generalizable data are available will determine how well this review documents usual care for LBP.

The aim was to synthesize evidence about current management of LBP in family practice and EDs. The specific objective was to describe the assessments, treatment advice, imaging, medication, and referrals provided in family practice or EDs to patients with LBP.

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