SIMPLE, first-line care incorporating advice, reassurance and self-management is the mainstay in managing most cases of non-specific low back pain in primary care, say experts writing in the MJA this week.
In a Guideline Review, experts have summarised key recommendations from guidelines recently released in the UK, Belgium, Denmark and the US.
The guidelines have several new messages for clinicians, such as an emphasis on simple first-line care and early follow-up within 1–2 weeks. For patients who need second-line care, the researchers say that non-pharmacological treatments, such as physical and psychological therapies, should be tried before pharmacological options are considered. If drug therapy is used, it should be used at the lowest effective dose for the shortest time possible, the researchers advised.
Surgical and interventional procedures have been found to be ineffective, they wrote.
Messages from previous guidelines have also been reinforced in this latest advice, the researchers wrote. These include the avoidance of routine imaging, the use of a triage approach when classifying patients presenting with low back pain, and the use of advice, reassurance and self-management as the cornerstone in simple, first-line care.
For patients with chronic non-specific low back pain, exercise and/or cognitive behavioural therapy has been recommended in the latest guidelines, the researchers reported.
The review comes after a team of international experts, led by Monash University’s Professor Rachelle Buchbinder, published a three-part series on low back pain in The Lancet. The series called for an overhaul of treatment practices, some of which were harmful, and recognition of the disability caused by back pain globally.
Lead author of the MJA guideline review, Professor Chris Maher, from the University of Sydney’s School of Public Health, said that the MJA review was in harmony with the position taken in The Lancet series.
“The MJA article provides more guidance for clinicians in how they should go about treating patients, but the messages are very well aligned,” said Professor Maher, who also contributed to The Lancet series.
He said that the article was a follow-up to a Narrative Review on the triage of low back pain, published in the MJA late in 2017.
In an MJA InSight podcast, Professor Maher said that there was a significant shift in the primary care management of non-specific low back pain, which accounted for about 95% of low back pain seen in primary care.
“GPs won’t be prescribing medicines as often as they have in the past, referrals for imaging and surgery will be uncommon,” Professor Maher said. “They will be working with the physiotherapist and psychologist, and they will be managing their patients with a non-drug approach. [They will be] talking to their patients confidently, helping them structure their lives so they can get back to what they want to do.”
Professor Maher said that the approach was a return to “good, old-fashioned general practice”.
Professor Buchbinder welcomed the review, saying that it fitted well with the international push for change in the management of non-specific low back pain.
Professor Buchbinder, who was lead author on an article in The Lancet series issuing a “call to action” for broader societal change on low back pain management, said that there were challenges ahead for clinicians and for patients.
“Among doctors, there is always the worry that we will miss something serious, so I can well appreciate that such worry would sometimes drive people to referring for imaging. On the other hand, I think GPs do have a really good understanding of needing to exclude serious causes of back pain,” she said.
“Things have changed. We now don’t want to prescribe medication unless it’s absolutely essential, but it’s very difficult when you have a patient in front of you with severe pain to say ‘we’re not going to give you any medication’.”
Professor Buchbinder said that once GPs had excluded serious causes for back pain, they should seek to identify the patients for whom simple first-line care was appropriate.
“[The goal is] to identify early the majority of people who only need advice to stay active and on how to manage [the pain] themselves, and to stay physically active in the future,” she said.
At the same time, she said, it’s important to identify people at high risk of having persisting problems.
“We now want to stratify [these patients] to get the help that they need earlier, to try to prevent those persisting disability problems.”
Professor Buchbinder said that these people may need exercise education with a physiotherapist or cognitive behavioural therapy with a psychologist.
The MJA review highlighted several, freely available risk stratification tools to support GPs in identifying patients at risk of longer term problems. These tools include: STarT Back, Örebro Musculoskeletal Pain Screening Questionnaire and PICKUP.
Professor Maher said that recent guidelines had also warned of the limited diagnostic accuracy of some individual red flags, such as night pain.
“The contemporary approach relies on a smaller set of red ﬂags than previously and emphasises the use of clusters of red ﬂags along with clinical expertise to guide decision making,” Professor Maher and co-authors wrote in the MJA.
Professor Maher agreed that patient expectations could be a barrier to change. He said that he hoped that patient involvement in upcoming research efforts through the Australia and New Zealand Musculoskeletal Clinical Trials Network would help to overcome some of these challenges.
Further support for GPs will also be available from October when NPS MedicineWise launches a national educational program aiming to improve the management of low back pain. The program will focus on: clinical diagnosis of non-specific low back pain and the limited role of imaging; early identification of chronic pain and disability; and activity as a primary treatment option, with medication playing a secondary supportive role.
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