What is Usual Care?      

This section is compiled by Frank M. Painter, D.C.
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Exploring Usual Care for Patients with Low Back Pain
in Primary Care: A Cross-sectional Study of
General Practitioners, Physiotherapists
and Chiropractors

BMJ Open 2023 (Aug 30); 13 (8): e071602 ~ FULL TEXT

The study points to a substantial variation in elements of care provided by GPs, PTs and DCs to patients with LBP. We provide some evidence that indicates differences in practice patterns between clinicians within and across professions that challenge the stereotypical images of clinicians and usual care as a uniform concept within groups of clinicians. Longitudinal data and qualitative enquiry are needed to assess if or how care is tailored to individual patients.

Primary Care for Low Back Pain:
We Don't Know the Half of It

Pain. 2020 (Apr); 161 (4): 663–665 ~ FULL TEXT

In a new systematic review, Kamper et al. [What is Usual Care for Low Back Pain?] (See it directly below this article) tackle the first question in relation to first-contact care for patients with low back pain provided by family practice and emergency department physicians. As the authors state, low back pain has major significance for the international pain community. It is the leading single cause of years lost to disability globally, [17] and there is good evidence for what constitutes best first-contact treatment. [6] The review selected best-quality studies of routine health care data to investigate whether first-contact physicians are putting back pain guidelines into practice (“usual care”). The results paint a bleak picture: only a minority of patients apparently receive simple positive messages to stay active and exercise, while inappropriate use of analgesia and imaging persists. The review adds to evidence that the care doctors give patients with low back pain is dominated by guideline-discordant interventions that are unnecessary, expensive, and “low-value” (ie, harm is more likely than benefit). [2, 3, 16]
Refer to our extensive collection, titled:
Initial Provider/First Contact

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

Pain. 2020 (Apr); 161 (4): 694–702 ~ FULL TEXT

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. 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.

Effect of Usual Medical Care Plus Chiropractic
Care vs Usual Medical Care Alone on Pain and
Disability Among US Service Members With Low
Back Pain: A Comparative Effectiveness
Clinical Trial
JAMA Network Open. 2018 (May 18); 1 (1): e180105 ~ FULL TEXT

Chiropractic care, when added to usual medical care (UMC), resulted in moderate short-term treatment benefits in both LBP intensity and disability, demonstrated a low risk of harms, and led to high patient satisfaction and perceived improvement in active-duty military personnel. This trial provides additional support for the inclusion of chiropractic care as a component of multidisciplinary health care for LBP, as currently recommended in existing guidelines. [21, 22, 37] However, study limitations illustrate that further research is needed to understand longer-term outcomes as well as how patient heterogeneity and intervention variations affect patient responses.
You will also enjoy this Invited Commentary, titled:
Innovating to Improve Care for Low Back Pain in
the Military: Chiropractic Care Passes Muster

You will also enjoy Medscape Medical News
review of this study, titled:

Chiropractic Care Improves Usual
Management for Low Back Pain

Comparison of Spinal Manipulation Methods and
Usual Medical Care for Acute and Subacute Low
Back Pain: A Randomized Clinical Trial

Spine (Phila Pa 1976). 2015 (Feb 15); 40 (4): 209–217 ~ FULL TEXT

Manual-Thrust Manipulation (MTM) provides greater short-term reductions in self-reported disability and pain scores compared with Usual Medical Care (UMC) or Mechanical-Assisted Manipulation (MAM).

A Comparison of Chiropractic Manipulation
Methods and Usual Medical Care for Low
Back Pain: A Randomized Controlled
Clinical Trial

J Altern Complement Med. 2014 (May); 20 (5): A22–23

The primary aim of this study was to compare manual and mechanical methods of spinal manipulation (Activator) for patients with acute and sub-acute low back pain. These are the two most common methods of spinal manipulation used by chiropractors, but there is insufficient evidence regarding their comparative effectiveness against each other. Our secondary aim was to compare both methods with usual medical care.

The Burden of Chronic Low Back Pain: Clinical
Comorbidities, Treatment Patterns, and Health
Care Costs in Usual Care Settings

Spine (Phila Pa 1976). 2012 (May 15); 37 (11): E668–677

Relative to controls, patients with CLBP had a greater comorbidity burden including a significantly higher (P < 0.0001) frequency of musculoskeletal and neuropathic pain conditions and common sequelae of pain such as depression (13.0% vs. 6.1%), anxiety (8.0% vs. 3.4%), and sleep disorders (10.0% vs. 3.4%). Pain-related pharmacotherapy was significantly greater (P < 0.0001) among patients with CLBP including opioids (37.0% vs. 14.8%; P < 0.0001), nonsteroidal anti-inflammatory drugs (26.2% vs. 9.6%; P < 0.0001), and tramadol (8.2% vs. 1.2%; P < 0.0001). Prescribing of "adjunctive" medications for treating conditions associated with pain (i.e., depression, anxiety, and insomnia) was also significantly greater (P < 0.0001) among patients with CLBP; 36.3% of patients received combination therapy. Health care costs were significantly higher in the CLBP cohort (P < 0.0001), reflecting greater resource utilization. Total direct medical costs were estimated at $8386 ± $17,507 in the CLBP group and $3607 ± $10,845 in the control group; P < 0.0001).

A Structured Protocol of Evidence-based
Conservative Care Compared with Usual
Care for Acute Nonspecific Low Back Pain:
A Randomized Clinical Trial

Arch Phys Med Rehabil. 2012 (Jan); 93 (1): 11–20 ~ FULL TEXT

Overall, the 2 treatment groups were similar based on primary or secondary outcome measure scores for the full treatment period (4 weeks, with up to 7 treatments). However, there were statistically significant and clinically meaningful differences in both disability and pain scores at week 2 (midpoint) with 4 treatments, suggesting that the protocol of care had a more rapid effect than usual care. The results of this study offer guidance to musculoskeletal practitioners, who regularly use manual and manipulative therapy (MMT) for acute LBP, that an evidence-based, structured protocol of care may yield comparable results to usual care in a shorter period with less treatment.

A Systematic Review on the Effectiveness of
Physical and Rehabilitation Interventions
for Chronic Non-specific Low Back Pain

European Spine Journal 2011 (Jan); 20 (1): 19–39 ~ FULL TEXT

In total 83 randomized controlled trials met the inclusion criteria: exercise therapy (n = 37), back school (n = 5), TENS (n = 6), low level laser therapy (n = 3), behavioural treatment (n = 21), patient education (n = 1), traction (n = 1), and multidisciplinary treatment (n = 6). Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. Behavioural treatment was found to be effective in reducing pain intensity at short-term follow-up compared to no treatment/waiting list controls. Finally, multidisciplinary treatment was found to reduce pain intensity and disability at short-term follow-up compared to no treatment/waiting list controls.

Exercise Therapy for Chronic
Nonspecific Low-back Pain

Best Pract Res Clin Rheumatol. 2010 (Apr); 24 (2): 193–204 ~ FULL TEXT

In total, 37 randomised controlled trials met the inclusion criteria and were included in this overview. Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. The authors conclude that evidence from randomised controlled trials demonstrated that exercise therapy is effective at reducing pain and function in the treatment of chronic low back pain. There is no evidence that one particular type of exercise therapy is clearly more effective than others. However, effects are small and it remains unclear which subgroups of patients benefit most from a specific type of treatment.

Low Back Pain and Best Practice Care:
A Survey of General Practice Physicians

Archives of Internal Medicine 2010 (Feb 8); 170 (3): 271–277~ FULL TEXT

It is clear from this study that the usual care provided by GPs does not align with best practice recommendations. The results indicate that in most cases, usual care is not evidence-based care and so is not likely to provide the best outcomes. Given that usual care is the control treatment in many trials38 evaluating new treatments for LBP, these trials may provide overly optimistic estimates of the effects of the new therapy. In our view, it would be more meaningful for future trials to use guideline-based care as the control treatment. This would have the advantage of being replicable and would provide an appropriate benchmark for comparison with new therapies. Moreover, while the focus in this study was the GP, it is unclear if other health care providers (eg, physiotherapists or chiropractors) who see patients with LBP are better in providing evidence-based care.

Cost Effectiveness of Physical Treatments
for Back Pain in Primary Care

British Medical Journal 2004 (Dec 11); 329 (7479): 1381 ~ FULL TEXT

We believe that this is the first study of physical therapy for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice. Indeed, as we trained practice teams in the best care of back pain, we may have underestimated the benefit of physical therapy (spinal manipulation) when compared with "usual care" in general practice. The detailed clinical outcomes reported in the accompanying paper reinforce these findings by showing that the improvements in health status reported here reflect statistically significant improvements in function, pain, disability, physical and mental aspects of quality of life, and beliefs about back pain.
Read both British Medical Journal articles
about the UK BEAM Trial


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