Saturday, February 20, 2010

Back Pain Treatment Guidelines Often Ignored

Back PainAcute lower-back pain is estimated to be among the most common reasons for visits to healthcare providers. However, according to an extensive survey, more often than not, patients receive back care that is inconsistent with best-practice guidelines.

Researchers in Australia prospectively examined usual care provided for acute lower-back pain (LBP) by general practitioners (GPs) in their country and compared this with best-practice recommendations in international evidence-based guidelines [Williams et al. 2010]. Their survey examined care provided by more than 2,300 community-based GPs during 3,533 patient visits specifically for new episodes of LBP. To establish recommended treatment criteria, the researchers critically appraised guidelines from Europe, United States, United Kingdom, and Australia, and a systematic review of guidelines. There was a general consensus within the guidelines that the following recommendations for the clinical management of acute LBP are most important:
  1. Use a diagnostic triage as a basis for management decisions and perform a more extensive examination if the medical history indicates possible serious disease or nerve root compromise.

  2. Do not routinely order radiological or ancillary investigations.

  3. Educate the patient; provide assurance of a favorable prognosis and encouragement to remain active and avoid bed rest.

  4. Regular acetaminophen (paracetamol) is the first choice of analgesic. When this provides insufficient analgesia, regular nonsteroidal anti-inflammatory drugs (NSAIDs) may be tried. (Some guidelines recommend medicines containing opioids when NSAIDs provide insufficient analgesia.)

  5. Review the patient's progress.
The researchers found that, although guidelines discourage the use of imaging for new cases of LBP, slightly more than one-quarter of patients (25.3%) were referred for imaging, primarily diagnostic x-rays and computed tomography. Nearly two-thirds of patients (65%) received a medication and, while guidelines recommend that initial care should focus on advice and simple analgesics (acetaminophen), only 21% and 18% of patients received these treatments, respectively. Instead, the analgesics provided were typically nonsteroidal anti-inflammatory drugs (37%) and opioids (20%), which are considered second-line therapies.

COMMENTARY: The researchers conclude that usual care provided by GPs for LBP does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. Furthermore, the unendorsed care may contribute to high costs of managing LBP and some aspects of the care provided carry a higher risk of adverse effects. One might question whether this situation is unique to Australia, but the researchers note similar outcomes of a study in the U.S. reported in 2005.

In fairness to the GPs in question, the researchers found that the average time for an office visit was a mere 20 minutes, which does not allow much leeway for also providing patient education and comforting advice. Also, no distinctions were made in the study regarding duration or severity of LBP prior to the first visit, or which analgesics or other approaches patients might already have tried on their own. Therefore, in many cases, imaging or strong analgesics may have seemed justified. The study authors also are critical that less than a third of patients prescribed acetaminophen received the “recommended dose” of 4,000 mg/day. Yet, this is widely considered the maximum threshold of safe daily intake of acetaminophen, so the practitioners should not be faulted for not going to that limit at the start. Furthermore, some guidelines have recently advocated that properly prescribed opioids for certain patients (eg, the elderly) have more favorable safety profiles than NSAIDs and are more effective than acetaminophen.

Finally, there is a question of whether current guidelines for LBP are of such high quality that healthcare providers should be faulted if they do not strictly adhere to them. We have previously expressed concerns that many guidelines in the pain management field appear to make strong recommendations based on collections of weak evidence [see, our discussion of Misguided Guidelines]. For this study, the researchers did consult a number of guidelines for LBP; however, were these of good quality? This is just a question for consideration since, admittedly, we did not examine each of those guidelines directly and the study authors do not comment in this regard.

Reference: Williams CM, Maher CG, Hancock MJ, et al. Low back pain and best practice care: a survey of general practice physicians. Arch Intern Med. 2010;170(3):271-277 [abstract here].