Back care doesn't measure up

According to national guidelines, the best care for acute lower back pain is simple: stay active, avoid bed rest and take regular simple analgesics such as paracetamol. However new research has found that only 20% of patients receive this simple treatment approach. Instead many are referred for unnecessary imaging and prescribed more complex medicines such as ibuprofen.

In Australia, acute low back pain is primarily managed by GPs, physiotherapists and chiropractors. New research conducted by The George Institute has revealed that the care received by patients does not align with best practice recommendations in international evidence-based guidelines.

Importantly, this care may not be providing the best outcomes for patients and is likely to be contributing to the high cost of back pain in Australia.

"We found a great difference between usual care and what is recommended in guidelines for treating acute lower back pain. For example, guidelines discourage the use of imaging, but more than one-quarter of patients were referred to imaging. Most patients did not receive the recommended advice even though this is inexpensive and universally recommended for all patients. The challenge is how we change practice so that it aligns with the evidence", said author Professor Chris Maher, Director of musculoskeletal research at The George Institute.

"One issue is the internet; it contains an interesting mix of information and misinformation. As a result treating back pain for clinicians is more difficult than ever because of common misconceptions patients bring with them to the consultation. A potential step in rectifying the situation is addressing these misconceptions with key public health messages."

Low back pain is the most prevalent and costly musculoskeletal condition in Australia , estimated to cost up to $1billion per annum with indirect costs exceeding $8billion . In the United States, the direct cost of treatment is over $50billion. The issues between care and guidelines have also been found in the United States, and highlight concern over what strategies are necessary to educate GPs in providing guideline-based care.

Researchers assessed the care of 3533 patients who visited their GP regarding a new case of low back pain. Treatment was mapped against international evidence-based guidelines for the management of lower back pain. The research also reviewed the impact of the introduction of guidelines in 2004, which showed that the treatment trends have not improved over time.

Paracetamol is endorsed in guidelines because it is a safe and cost-effective treatment. However the true efficacy of paracetamol for a new episode of low back pain is unclear, and authors note that perhaps because of this uncertainty only 20% of patients with new low back pain are prescribed or recommended paracetamol.

"We know that most people with back pain do not take paracetamol correctly in fact, less than 10% of patients with a new episode of low back pain take paracetamol regularly up to the daily recommended dose", said Professor Maher.

Researchers are now investigating the effects of paracetamol among 1650 patients from GP practices in the Sydney metropolitan area, and will follow patients’ recovery for three months. This study will find out whether taking paracetamol regularly is more effective than taking paracetamol on an as-required basis. The results of this new study will have immediate implications for clinical management of low back pain.

"If the findings demonstrate that a regular course of paracetamol is effective in speeding recovery, the cost-savings to individual patients and to our healthcare system will be very significant, especially for the 4 million people with back pain in Australia", added Professor Maher.

The new study is being conducted at The George Institute with colleagues at the University of Sydney and University of New South Wales.