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:
- 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.
- Do not routinely order radiological or ancillary investigations.
- Educate the patient; provide assurance of a favorable prognosis and encouragement to remain active and avoid bed rest.
- 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.)
- Review the patient's progress.
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.