A recent review examined how well family practice and emergency department physicians follow recommended guidelines on managing low back pain. See what they found with these 10 questions.
Low back pain (LBP) is one of the most common problems for which patients seek care from physicians. Multiple guidelines have been issued on the best practices in managing LBP and they are generally in agreement regarding these.
A recent paper reviewed the studies that have examined whether family practice (FP) and emergency department (ED) physicians follow the recommendations of the guidelines in 26 studies published between 2003 and 2018, involving 194 388 patients. The following 10 questions are based on the results.
Question 1. True or false? Based on the studies reviewed, the authors concluded that FP and ED physicians both do a good job in identifying whether patients with LBP have red flags that may indicate serious underlying pathology.
Answer: B. False. The authors reported that based on the studies they reviewed, they were unable to determine how good a job either FP or ED physicians did at identifying red flags.
Question 2. True or false? For most patients with LBP, in the absence of any red flags indicating serious underlying pathology, treatment should include education and reassurance.
Answer: A. True. Education and reassurance are considered vital parts of treatment of patients with LBP. Of greatest importance is assuring patients that there are no signs that there is any severe underlying pathology, a common fear, and that the best thing is to exercise and remain active.
Question 3. What percentage of LBP patients actually appear to receive education and reassurance from FP physicians?
Answer: B. 20%. Despite the recommendation that most patients be given reassurance and education by their FP physicians, only this relatively small percentage actually appear to receive it. Reviewers were unable to find studies indicating that ED doctors were following this guidance.
Question 4. Guidelines recommend that most patients with LBP need to be referred for which of the above imaging studies?
Answer: E. None of the above. Most patients with LBP don't require imaging studies. Imaging should be reserved for patients exhibiting red flags (<5% of cases) that suggest the possibility the pain might be due to serious underlying pathology.
Question 5. Approximately what percentage of patients with LBP are referred by FP physicians for imaging studies?
Answer: B. 25%. Approximately 25% of patient with LBP are referred for imaging studies by FP physicians.
Question 6. Approximately what percentage of patients with LBP are referred by ED physicians for imaging studies?
Answer: C. 33%. Approximately 33% of patients with LBP are referred by ED physicians for imaging studies.
Question 7. Based on previous studies, review authors concluded that with regard to imaging studies, both FP and ED physicians do which of the above?
Answer: D. All of the above. Although it appears that many patients for whom imaging studies are not indicated are still referred for them and that doing so can lead to unnecessary treatments, studies also show that >50% of patients with red flags that do indicate the need for imaging.
Question 8. With regard to medication management of LBP, the guidelines recommend which of the above as first-line treatments?
Answer: A. NSAIDS and acetaminophen. NSAIDS and acetaminophen are considered first-line medications for the management of LBP. With regard to opioids, guidelines recommend they rarely be prescribed for acute LBP and essentially never for chronic LBP.
Answer: C. 30%. This suggests that opioids may be over-prescribed for patients with LBP by FP physicians. The percentage of patients prescribed opioids by ED doctors ranged from 20% to 60%.
Question 10. True or false? The greater use of imaging studies and greater number of opioid prescriptions written by ED physicians vs FP physicians have been proven to be due to the fact that patients seen by ED physicians are more likely to have red flags indicating severe underlying pathology and have more severe pain.
Answer: B. False. Although it is conjectured that LBP patients seen by ED physicians are more likely to have red flags indicating potential serious underlying pathology and that their pain is more likely to be more severe than those seen by FP physicians, this has yet to be proven and there is no evidence that the LBP patients seen by the 2 groups of physicians are markedly different.
Reference: Kamper SJ, Logan G, Copsey B, et al. What is usual care for low back pain? A systematic review of health care provided to patients with low back pain in family practice and emergency departments. Pain. 2020;161:694-702.