Pain. 2020 (Apr); 161 (4): 694–702 ~ FULL TEXT
Steven J Kamper, Gabrielle Logan, Bethan Copsey, Jacqueline Thompson3, Gustavo C Machado1 et al,
Institute for Musculoskeletal Health,
Faculty of Medicine and Health,
University of Sydney, Australia.
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.
PROSPERO Registration CRD42018070241
Keywords: low back pain; usual care; Family Medicine; emergency department; imaging; Opioids
From the FULL TEXT Article:
Low back pain (LBP) is an extremely common condition with a mean lifetime prevalence of
around 40%  and is the leading cause of disability globally.  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.  The condition also has considerable implications for
society as a whole due to the costs of healthcare, reduced work productivity, early retirement
and strains on the welfare system. [19, 49]
Recently updated clinical practice guidelines for LBP from Canada, the United States and the
United Kingdom (UK) 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] following a large RCT and subsequent
systematic review published in 2015. [32, 55] These guidelines are based on high quality
evidence and widely endorsed by professional organisations. Recommended assessment
involves diagnostic triage [3, 52] based on patient history and physical examination to exclude
patients with a problem beyond the lumbar spine (e.g. renal colic) and then categorise patients
into one of three groups. A) non-specific LBP, B) lumbar radicular syndromes (sciatica and
canal stenosis), or C) a serious pathology affecting the lumbar spine (e.g. infection, fracture,
cancer). In family practice and emergency departments, more than 90% of lumbar spine
problems fall into categories A or B. [20, 51]
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,  however, there are few data available to confirm this suspicion.
Recommended first line treatment for patients with LBP includes; advice to remain active,
and education and reassurance. Adjunctive options include application of heat, manual
therapy, non-steroidal anti-inflammatory drugs, and structured exercise and cognitive
behavioural therapy for patients with persistent symptoms.  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.
While these recommendations are well established over several years, and health providers
report being aware of them, [42, 54] there are concerns about substantial gaps between
guideline recommendations and the care delivered in usual practice.  Individual studies
report high rates of imaging , opioid prescription , 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
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 low back pain.
The aim was to synthesize evidence about current management of LBP in family practice and
emergency departments (ED). The specific objective was to describe the assessments,
treatment advice, imaging, medication and referrals provided in family practice or EDs to
patients with LBP.
Prospectively registered systematic review, PROSPERO 2018 CRD42018070241.
Data sources and Searches
An electronic search was conducted in three databases (EMBASE, PubMed-Medline, and
CINAHL) using search terms related to “back pain”, “guideline recommendations”, and
“medical records” from inception to May 2019 (eTable 1, available as supplemental digital
content at http://links.lww.com/PAIN/A913). Further potentially relevant studies were
identified via consultation with experts and citation tracking on the included studies.
Studies were included if they: (1) reported family practice or ED physicians’ assessment
and/or treatment of adult patients (aged >18 years) with LBP of any duration and, (2) had a
quantitative design assessing actual treatment records. Qualitative studies and studies that
measured usual care via recall or hypothetical scenarios/vignettes were not included. Studies
that analysed data from prior to 2000 were excluded as we were not interested in historical
patterns of practice. Grey literature including non-peer-reviewed literature, theses and letters
to the editor were not included. Non-English language studies were included and translated as
necessary. A full list of the eligibility criteria appears in eTable 2 (available as supplemental
digital content at http://links.lww.com/PAIN/A913). Two reviewers independently screened
all titles and abstracts, and then potentially eligible full texts. Disagreements were resolved by
discussion, arbitrated by a third reviewer as needed.
Two reviewers independently extracted study characteristics and outcomes data into an Excel
spreadsheet. Study characteristics included; healthcare setting, LBP duration, period of data
collection, data source, and sample size. Family practice was defined as primary-contact
outpatient/ambulatory care that was not in ED. For each outcome, data were extracted on
collection method, metric used to assess utilisation (e.g. proportion or rate), and the
denominator used (e.g. episodes of care, number of patients). Studies most commonly
reported the proportion of patients that received a particular aspect of care, which could have
been at a single appointment or over a number of visits, we categorised this as ‘per patient’.
Fewer studies reported the proportion of visits that involved that aspect of care, we
categorised this as ‘per episode’ of care. One study reported the proportion of physicians that
delivered that aspect of care; ‘per physician’.
Reporting and Methodological Quality
The STROBE (STrength of Reporting in OBservational Studies in Epidemiology) Statement
and its extension statement entitled RECORD (REporting of studies Conducted using
Observational Routinely-collected health Data) were used to assess the transparency of
reporting. We used items from key domains for assessing susceptibility to bias in
observational studies as recommended in Sanderson et al.  This includes items in 4
domains; representativeness of the sample, potential misclassification of patients, potential
misclassification of outcomes, and inconsistent data. Because we used methodological quality
to prioritise interpretation of findings, we also considered precision as an indicator of study
quality. Included studies were considered high quality if they met criteria for ≥4 of 5 items.
Findings from included studies were divided by healthcare setting (family practice or ED) and
organised according to outcome category: assessments, treatment advice, imaging,
medication, referrals. Within each outcome category (e.g. Imaging) individual types are
described separately (e.g. x-ray, CT, MRI, any image). We planned meta-analysis of single
proportions, however clinical heterogeneity prevented meta-analysis for any outcome. We
present all available estimates in the tables and focus our interpretation on the range of
estimates that came from the high quality studies. A narrow range of high quality estimates
from several studies provided greater confidence in the findings, and vice-versa.
Characteristics of included studies
The database and hand searches yielded 989 titles, of which 26 studies were included (Figure
1). The 26 studies reported data from a total of 194,388 patients, 18 studies were in family
practice and 8 from emergency departments (Table 1). A further two studies that collected
data from mixed settings were not included in the main analyses but findings are reported in
eTable 3 (available as supplemental digital content at http://links.lww.com/PAIN/A913).
Studies were published between 2003 and 2018. Most studies included patients with LBP of
any duration, however, 6 included patients with acute LBP only. Studies most commonly
reported data from routinely collected medical records in hospital administrative databases
(n= 20), followed by insurance claims or worker compensation databases (n= 3).
Transparency of Reporting
Most studies met criteria on most items in the STROBE checklist (eTable 4, available as
supplemental digital content at http://links.lww.com/PAIN/A913). The main areas of poor
reporting related to the extended RECORD checklist items, specifically with respect to data
capture from medical records. These included reporting who had access to the database and
created the database of the study, what codes were used select participants and outcome
variables from the database, if the codes were validated and if data linkages were required to
obtain variables and if so, how the linkage was conducted.
Nearly all included studies met criteria for consistency of data and representativeness of the
sample, 12 used methods to limit bias due to patient misclassification, 15 used methods to
limit bias due to misclassification of the outcome, and 15 studies reported on sufficiently
large samples to provide precise estimates (eTable 5, available as supplemental digital content
at http://links.lww.com/PAIN/A913). We considered sufficient precision to be confidence
intervals with a width of 5% or less. According to our criteria, 12 studies provided high
quality evidence (Table 1).
Components of usual care
There was often considerable variability in the proportions of patients that received
assessments, various types of treatment advice, imaging, medication or referrals. This
heterogeneity was in part due to differences in measurement between studies, and precluded
meta-analysis. Method of measurement was an important source of heterogeneity, most
commonly studies either reported rates (of assessments, images etc) per single patient visit
(per patient), or per patient over multiple visits (per episode). To focus on the most reliable
estimates of usual care, we only describe results from the high-quality studies in the text of
the Results, data from all included studies appears in the Tables.
Assessments were categorised into four types; assessment of red flags, history taking,
physical examination, and neurological examination. There were no high-quality estimates of
rates for any of the assessments (eTable 6, available as supplemental digital content at
Treatment advice was categorised into five types; education and reassurance, exercise, bed
rest, return to work and sickness certificates (Table 2). In family practice settings, two highquality
studies reported that 21% and 23% of patients received education or reassurance, one
study reported that 19% of patients received exercise advice, and 3% a sick certificate. There
were no high-quality estimates for advice regarding bed rest or return to work. There were no
high-quality estimates for any of these types of advice in ED.
Imaging referral was categorised into five types; X-Ray, CT scan, MRI, CT or MRI, any
image (Table 3). Four studies reported that between 16 and 20% of patients received referral
for X-Ray from family practice, in ED the proportion was 30%. Three studies in family
practice reported rates of 2 to 6% for CT scans, and one study in ED reported 6%. Three
studies estimated that <1 and 5% of family practice patients were referred for MRI, two ED
studies reported 3% and 25%. Ten percent of family practice patients, and 7 to 18% of ED
patients received an MRI or CT. Three studies reported that 11 to 26% of family practice
patients received referral for an image of any type, and two studies in ED reported 29 and
Medication recommendations were divided into four categories; paracetamol, non-steroidal
anti-inflammatory drugs (NSAIDs), muscle relaxants, and opioids (including in combination
with other analgesics) (Table 4). Where specified in the included studies, the data for EDs
relate to medications provided in ED, as opposed to recommended after discharge. In family
practice, three studies reported that paracetamol was recommended to 6 to 18% of patients, in
ED, the proportion was 4%. NSAIDs were recommended to 36 to 37% of family practice
patients, and 50% of ED patients. Muscle relaxants were recommended to 1 to 8% of family
practice patients, and 42% of ED patients. Opioids, including in combination with other
analgesics were prescribed to 5 to 31% of family practice patients, and two studies in ED
reported rates of 17 and 61%.
Treatment referrals were divided into four categories; physiotherapy, chiropractic, surgery,
medical specialist (Table 5). In family practice, three studies reported that 14 to 27% of
patients received physiotherapy referral. Three studies reported that up to 10% of patients
were referred from family practice for surgical consult, in ED this figure was 8%. In family
practice four studies reported that 1% to 19% of patients received referral to a medical
Statement of main findings
The high-quality estimates for Family Practice suggest around 1 in 4 patients were sent for
lumbar imaging, about 20% recommended paracetamol, 35-40% NSAIDs, and up to 30%
prescribed opioids. While there were fewer high-quality estimates from ED, the rates of
imaging, and medication use were higher (except for paracetamol); around 1 in 3 patients got
some type of image, 50% received NSAIDs, and somewhere between 20 and 60% were
provided opioids while in ED.
Only around 20% of patients received education, reassurance, and advice regarding exercise
from their family practitioner. We found no high-quality data concerning the provision of
advice regarding bed rest and return to work, and no high-quality data regarding treatment
advice at all for ED settings. Family practitioners referred around 15 to 20% of patients for
physiotherapy, 1 to 20% to a medical specialist and up to 6% to a surgeon, approximately 8%
of patients in ED were referred for surgical review. We found no high-quality estimates on
how many patients received recommended assessments such as red flag assessment, physical,
and neurological examination and history taking.
Interpretation in context of other literature
It is important to take a nuanced approach to interpretation of these findings with respect to
clinical practice guideline recommendations and epidemiological evidence. For example,
guidelines recommend “Do not routinely offer imaging in a non-specialist setting for people
with low back pain without alerting features of serious pathology”  and robust evidence
suggests that prevalence of serious spinal pathology, for which imaging is indicated, in
primary care is <5%.  In this context, rates in excess of 25% appear to indicate overuse of
However, these data do not tell us about the reasons for imaging referral, and hence
what proportion were inappropriate. A recent systematic review of 33 studies considering
appropriateness of imaging for low back pain and estimated that referral was inappropriate in
7 to 28% of the patients referred for imaging that presented for care. The same review also
found that 60-65% of patients were not referred for imaging despite the presence of red flags
or clinical suspicion of serious pathology.  Hence, issues of overuse and underuse may
both occur. Overuse of imaging may lead to poorer outcome,  which means that efforts to
reduce the volume of unnecessary imaging are appropriate.  However, understanding the
reasons for referral is a pre-requisite to designing these efforts, for example some studies
suggest that patient or physician beliefs may drive imaging. 
Current guidelines recommend that patients are provided NSAIDs as first line
pharmacological treatment, and that use of opioids be limited in those with acute low back
pain, and not provided at all for chronic low back pain.  Our findings show that less than
half of patients were prescribed NSAIDs, up to third received opioids in family practice and
up to twice that proportion in ED. Clinical practice guidelines do not offer distinct
recommendations for care provided in ED and family practice settings. There is a perception
that patients who present to ED have on average more severe symptoms, and are more likely
to have a serious spinal pathology such as fracture, cauda equina or acute infection.  If this
is the case higher rates of diagnostic imaging in ED than family practice may be appropriate,
although this is not to suggest that the rates observed in our study are reasonable.
By the same
argument, higher rates of prescription of powerful analgesics may also appear warranted,
although this is to ignore important questions about the effectiveness of these medications 
and well-established concerns regarding potential harms including overdose and death. 
While data regarding the provision of advice are sparse, only approximately 1 in 5 patients
visiting family practice were provided education, reassurance and advice regarding exercise.
These findings indicate that evidence-based advice was not routinely delivered to patients
with LBP in primary care.
High quality estimates come from studies conducted in a small number of countries only. Of
the nine high quality family practice studies 3 are from the USA, 3 from Australia and 1 each
from Netherlands, Italy and Spain, all of the 4 high quality ED studies come from USA. This
raises the question of how well the results from this review represent usual care in other
countries. Delivery of the different components of care could be influenced by structural
aspects of the healthcare such as access, training of practitioners, and reimbursement
processes, legislative constraints operating at the government level, by cultural aspects within
a service, region or country, or other factors. We are not able to determine whether variability
in the estimates presented in this review are due to any of these factors.
Strengths and limitations
This review was conducted according to contemporary best practice methods including
registration of the protocol prior to commencement of data extraction, and double screening
and data extraction. Inclusion of studies that made use of routinely-collected data ensured that
we gained a true representation of ‘usual care’, and incorporation of study quality into our
data synthesis focused our interpretation on the most reliable estimates.
As is the case for all systematic reviews, clinical and methodological heterogeneity between
the included studies leads to variation in the estimates. A further limitation is that many
aspects of care are typically not well captured and coded in routine clinical data collection
systems. This is most likely to influence our findings related to assessments and treatment
advice. The issue is reflected in the fact that we found few high-quality estimates of these
components, it also means that we have low confidence that the data reported in lower quality
studies provide a reliable reflection for these aspects of usual care.
Our study focusses on
usual care provided by physicians, and so may not be generalizable to other healthcare
professions such as physical therapists and chiropractors who are first-contact providers in
some jurisdictions. We found relatively few studies that provided high quality data and these
tended to be concentrated in a small number of western countries, this means that the nature
of usual care may deviate substantially from our findings in other countries and jurisdictions.
The included studies span approximately 15 years, in this time practice patterns may have
changed as new evidence has accumulated, our synthesis does not account for any change
over this period.
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 LBP.
Commentators have proposed that responses to these problems may come from the top-down,
whereby governments, payers and system administrators enact changes, and from the bottom
up, where the public and clinicians alter practice to align with best available evidence. 
Numerous top-down initiatives may serve this purpose including: removal of capacity within
the system to provide inappropriate care, financial restrictions, education and support for
clinicians, and revision of diagnostic criteria and thresholds. Additionally, stakeholder
(clinicians and patients) engagement, support for shared decision-making, and inclusion of
(in)appropriate use recommendations in clinical practice guidelines may improve alignment
of clinical services with best available evidence.
From a policy perspective, the findings also highlight the need for health systems to invest in
and maintain data collection infrastructure. Robust clinical audits are only possible if there is
reliable and complete capture of clinical data, such audits being vital to identify problems and
inefficiencies in patient care, and evaluate whether remedial strategies are effective. An
important barrier to useful audits of practice involves numerous and disconnected data
collection and storage systems within institutions, for example imaging, medication
prescription, admission and clinical notes may all be located in different databases that are not
easily linked. It is noted that this presents a barrier to effective care delivery as well as
Dependable information about what constitutes usual medical care for low back pain is also
critical for interpreting clinical research, as ‘usual care’ is often used as a comparator (control)
in pragmatic trials. If usual care is of poor quality, showing that a new therapy provides better
outcome may not provide convincing evidence for the new therapy. At a minimum, it is
important to describe the care typically received in the usual care arm  so that readers can
assess the trial results. These data can also identify system, country and international trends,
for example in medication use, or intervention provision. Information such as this can inform
research priorities and targets for funding.
Our study also highlights the need for much more
fine-grained information about the reasons for decisions made in clinical practice. This might
involve a field that links medication or imaging referral specifically to an indication. Machine
learning applications may also assist in this regard by generating algorithms to convert
clinical notes into categorical fields that enable data users to link indications to treatment or
referrals. For example, only by understanding the basis for prescription of opioids can we
determine whether action needs to be taken, and if so, what the most promising targets for
changing prescribing behaviour might be.
Usual care for patients with low back pain did not align well with recommendations in
clinical practice guidelines. Around one in four patients that presented to family practice, and
one in three that presented to ED with back pain were referred for imaging. Around 35% and
50% of patients received NSAIDs in family practice and ED respectively. Rates of
prescribing of opioids were up to 30% in family practice and up to 60% of patients received
an opioid while in ED. Only around 20% of patients received information and advice that
aligns with clinical practice guideline recommendations.
None of the authors have conflicts of interest to declare. There was no funding for this study.
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