Initial Management of Acute and Chronic Low Back Pain: Responses from Brief Interviews of Primary Care Providers

Abstract

Background: In April 2017, the American College of Physicians (ACP) published a clinical practice guideline for low back pain (LBP) recommending nonpharmacologic treatments as first-line therapy for acute, subacute, and chronic LBP.Objective: To assess primary care provider (PCP)-reported initial treatment recommendations for LBP following guideline release.Design: Cross-sectional structured interviews.Participants: Convenience sample of 72 PCPs from 3 community-based outpatient clinics in high-or low-income neighborhoods.Approach: PCPs were interviewed about their familiarity with the ACP guideline, and how they initially manage patients with acute/subacute and chronic LBP. Treatment responses were coded as patient education, nonpharmacologic, pharmacologic, or medical specialty referral. PCPs were also asked about their comfort referring patients to nonpharmacologic treatment providers, and about barriers to referring. Responses were assessed using content analysis. Differences in responses were assessed using descriptive statistics.Key results: Interviews were completed between December 2017 and March 2018. Of 72 participating PCPs (50% male; mean years of practice = 13.8), over three-fourths indicated being familiar with the ACP guideline (76%-87% at 3 clinics). For acute LBP, PCPs typically provided advice to stay active (81%) and pharmacologic management (97%; primarily nonsteroidal anti-inflammatory drugs). For chronic LBP, PCPs were more likely to recommend nonpharmacologic treatments than for acute LBP (85% vs. 0%, p < 0.001). The most common nonpharmacologic treatments recommended for chronic LBP were physical therapy (78%), chiropractic care (21%), massage therapy (18%), and acupuncture (17%) (each compared with 0% for acute LBP, all p < 0.001). The cost of nonpharmacologic treatments was perceived as a barrier. However, PCPs working in low-income neighborhood clinics were as likely to recommend nonpharmacologic approaches as those from a high-income neighborhood clinic.Conclusions: While most PCPs indicated they were familiar with the ACP guideline for LBP, nonpharmacologic treatments were not recommended for patients with acute symptoms. Further dissemination and implementation of the ACP guideline are needed.

Low back pain service utilization and costs: association with timing of first-line services for individuals initially contacting a primary care provider. A retrospective cohort study

“…Previous studies have found that administrative burden and the cost of non-pharmacologic therapies are perceived as referral barriers by PCPs 21,22 . This study found first-line therapies are generally incorporated in addition to, rather than as an alternative to, second- and third-line therapies.…”

Neck pain care pathways and costs: association with the type of initial contact health care provider. A retrospective cohort study

“…The second is, when appropriate, supporting primary care and specialist HCPs in making timely referrals for non-pharmacologic services. Potential barriers to greater use of non-pharmacologic therapies identified in previous studies included the cost of non-pharmacologic therapies, weak evidence supporting efficacy of non-pharmacologic therapies, and administrative burden associated with referring individuals to a non-prescribing HCP 45,46 .…”

Implementation of Psychologically Informed Physical Therapy for Low Back Pain: Where Do We Stand, Where Do We Go?

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