European Spine Journal

, Volume 12, Issue 6, pp 589–594 | Cite as

Routine primary care management of acute low back pain: adherence to clinical guidelines

  • Violeta González-Urzelai
  • Loreto Palacio-Elua
  • Josefina López-de-Munain
Original Article

Abstract

One of the major challenges for general practitioners is to manage individuals with acute low back pain appropriately to reduce the risk of chronicity. A prospective study was designed to assess the actual management of acute low back pain in one primary care setting and to determine whether existing practice patterns conform to published guidelines. Twenty-four family physicians from public primary care centers of the Basque Health Service in Bizkaia, Basque Country (Spain), participated in the study. A total of 105 patients aged 18–65 years presenting with acute low back pain over a 6-month period were included. Immediately after consultation, a research assistant performed a structured clinical interview. The patients’ care provided by the general practitioner was compared with the Agency for Health Care Policy and Research (AHCPR) guidelines and guidelines issued by the Royal College of General Practitioners. The diagnostic process showed a low rate of appropriate use of history (27%), physical examination (32%), lumbar radiographs (31%), and referral to specialized care (33%). Although the therapeutic process showed a relatively high rate of appropriateness in earlier mobilization (77%) and educational advice (65%), only 23% of patients were taught about the benign course of back pain. The study revealed that management of acute low back pain in the primary care setting is far from being in conformance with published clinical guidelines.

Keywords

Low back pain Primary health care Physicians, family Practice guidelines 

Notes

Acknowledgements

We are grateful to physicians from the primary care center of Albia, Bombero Etxaniz, Casco Viejo, and Deusto that collaborated in the study, recruiting patients, and to Marta Pulido, MD, for editing the manuscript and editorial assistance.

References

  1. 1.
    American Academy of Family Physicians (1996) Facts about family practice. American Academy of Family Physicians, Kansas City, p 62Google Scholar
  2. 2.
    Andersson GBJ (1991) The epidemiology of spinal disorders. In: Frymoyer JW (ed) The adult spine: principles and practice. Raven Press, New York, pp 107–146Google Scholar
  3. 3.
    Anitua C, Aizpuru F, Sanzo JM (1997) Health Survey of the Basque Autonomous Community (in Spanish). Departamento de Sanidad, Gobierno Vasco, Vitoria-GasteizGoogle Scholar
  4. 4.
    Atlas SJ, Volinn E (1997) Classics from the spine literature revisited: a randomized trial of 2 versus 7 days of recommended bed rest for acute low back pain. Spine 22:2331–2337PubMedGoogle Scholar
  5. 5.
    Bigos S, Bowyer O, Braen G, et al (1994) Acute low back problems in adults. Clinical practice guideline, quick reference guide no. 14. AHCPR Pub. No. 95–0643. Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, RockvilleGoogle Scholar
  6. 6.
    Borenstein DG (1997) Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain. Curr Opin Rheumatol 9:144–150PubMedGoogle Scholar
  7. 7.
    Brook RH (1994) Appropriateness: the next frontier (editorial). BMJ 308:218–219PubMedGoogle Scholar
  8. 8.
    Burton AK, Waddell G, Tillotson KM, Summerton N (1999) Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care. Spine 24:2484–2491CrossRefPubMedGoogle Scholar
  9. 9.
    Cabana M, Rand C, Powe N, et al (1999) Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 282:1458–1465PubMedGoogle Scholar
  10. 10.
    Caminal J, Rovira J, Segura A (1999) Suitability of the prescription of antibiotic treatment in primary health care and costs of inappropriate use (in Spanish). AATM-Breus (BR9903). AATM, BarcelonaGoogle Scholar
  11. 11.
    Cherkin DC, Deyo RA, Battié M, Street J, Barlow W (1998) A comparison of physician therapy, chiropractic manipulation and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 339:1021–1029Google Scholar
  12. 12.
    Deyo RA, Tsui-Wu YJ (1987) Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine 12:264–268PubMedGoogle Scholar
  13. 13.
    Deyo RA, Diehl AK, Rosenthal M (1986) How many days of bed rest for acute low back pain? A randomized clinical trial. N Engl J Med 315:1064–1070PubMedGoogle Scholar
  14. 14.
    Fowler PBS (1997) Evidence-based diagnosis. J Evaluation Clin Pract 3:153–159Google Scholar
  15. 15.
    Goldberg D (1978) The general health questionnaire. Nfer-Nelson, WindsorGoogle Scholar
  16. 16.
    González Viejo MA, Condón Huerta MJ (2000) Disability from low back pain in Spain (in Spanish). Med Clin (Barc) 114:491–492Google Scholar
  17. 17.
    Hutchinson A, Waddell G, Feder G, et al (1996) Low back pain evidence review. Royal College of General Practitioners, LondonGoogle Scholar
  18. 18.
    Kahan JP, Bernstein SJ, Leape LL, et al (1994) Measuring the necessity of medical procedures. Med Care 32:357–365PubMedGoogle Scholar
  19. 19.
    Klaber Moffett J, Richardson G, Sgeldon TA, Maynard A (1995) Back pain. Its managament and cost to society. University of York, Heslington, YorkGoogle Scholar
  20. 20.
    Lafuma A, Fagnani F, Vautravers P (1998) Management and cost of care for low back pain in primary care settings in France. Rev Rhum Engl Ed 65:119–125PubMedGoogle Scholar
  21. 21.
    Little P, Smith L, Cantrell T, Chapman J, Langridge J, Pickering R (1996) General practitioners’ management of acute back pain: a survey of reported practice compared with clinical guidelines. BMJ 312:485–488PubMedGoogle Scholar
  22. 22.
    López-de-Munain J, Torcal J, López V, Garay J (2001) Prevention in routine general practice: activity patterns and potential promoting factors. Prev Med 32:13–22PubMedGoogle Scholar
  23. 23.
    Malmivaara A, Häkkinen U, Aro T, et al (1995) The treatment of acute low back pain—bed rest, exercise, or ordinary activity? N Engl J Med 332:351–355PubMedGoogle Scholar
  24. 24.
    Meneu R (2000) Costs of the inadequate health interventions (in Spanish). FMC-Formación Médica Continuada en Atención Primaria 7:378–385Google Scholar
  25. 25.
    Pascual Gil O, Doral Alvarez MD, Guerra de la Torre MG, Alonso Paniagua MA, Sanchez-Castro Monge MJ (1985) Epidemiological study of back pain in different population groups in the province of Guadalajara (in Spanish). Aten Primaria 6:367–368Google Scholar
  26. 26.
    Quebec Task Force on Spinal Disorders (1987) Scientific approach to the assessment and management of activity-related spinal disorders. A monograph for clinicians. Spine 12 [7 Suppl]:1–59Google Scholar
  27. 27.
    Roland M, Morris R (1983) A study of the natural history of back pain. I. Development of a reliable and sensitive measure of disability in low-back pain. Spine 8:141–144PubMedGoogle Scholar
  28. 28.
    Sabaté López P, Bestratén Bellobi J, Llor Vila JL, et al (1992) Lumbago cases seen at a health centre (in Spanish). Aten Primaria 9:208–211PubMedGoogle Scholar
  29. 29.
    Schroth WS, Schectman JM, Elinsky EG, Panagides JC (1992) Utilization of medical services for the treatment of acute low back pain: conformance with clinical guidelines. J Gen Intern Med 7:486–491PubMedGoogle Scholar
  30. 30.
    Scott J, Huskisson EC (1976) Graphic representation of pain. Pain 2:175–184PubMedGoogle Scholar
  31. 31.
    Suarez-Almazor ME, Belseck E, Russell AS, Mackel JV (1997) Use of lumbar radiographs for the early diagnosis of low back pain. Proposed guidelines would increase utilization. JAMA 277:1782–1786PubMedGoogle Scholar
  32. 32.
    Torstensen TA, Ljunggren AE, Meen HD, Odland E, Mowinckel P, af Geijerstam S (1998) Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self-exercise in patients with chronic low back pain. A pragmatic, randomized, single-blinded, controlled trial with 1-year follow-up. Spine 23:2616–2624PubMedGoogle Scholar
  33. 33.
    Tulder MW van, Scholten RJPM, Koes BW, Deyo RA (2000) Non-steroidal anti-inflammatory drugs for low back pain (Cochrane Review). In: The Cochrane Library, Issue 1. Update Software, OxfordGoogle Scholar
  34. 34.
    Von Korff M, Deyo RA, Cherkin D, Barlow W (1993) Back pain in primary care: outcomes at one year. Spine 18:855–862PubMedGoogle Scholar
  35. 35.
    Vroomen PCAJ, de Krom MCTFM, Wilmink JT, Kester ADM, Knottnerus JA (1999) Lack of effectiveness of bed rest for sciatica. N Engl J Med 340:418–423PubMedGoogle Scholar
  36. 36.
    Waddell G (1987) A new clinical model for the treatment of low-back pain. Spine 12:632–644PubMedGoogle Scholar
  37. 37.
    Watson PJ, Main CJ, Waddell G, Gales TF, Purcell-Jones G (1998) Medically certified work loss, recurrence and costs of wage compensation for back pain: a follow-up study of the working population of Jersey. Br J Rheumatol 37:82–86PubMedGoogle Scholar
  38. 38.
    Weber H (1983) Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine 8:131–140PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2003

Authors and Affiliations

  • Violeta González-Urzelai
    • 1
    • 2
  • Loreto Palacio-Elua
    • 1
  • Josefina López-de-Munain
    • 3
  1. 1.Gazteleku Health CenterBasque Health ServiceBilbaoSpain
  2. 2.Unidad de Investigación de Atención Primaria de BizkaiaBilbaoSpain
  3. 3.Primary Care Research Unit of BizkaiaBasque Health ServiceBilbaoSpain

Personalised recommendations