Original Report| Volume 17, ISSUE 1, P27-35, January 2016

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Investigating the Primary Care Management of Low Back Pain: A Simulated Patient Study

Published:October 05, 2015DOI:


      • Selection of pain medicines was consistent with low back pain guidelines.
      • Provision of self-care advice and medicines information was lacking.
      • There was a low rate of prompt medical referrals for the fracture scenario.


      A limitation of existing studies of primary care for low back pain (LBP) is that they are not based on direct observation of the clinical encounter and so may underestimate or overestimate the extent of evidence-practice gaps. This was a cross-sectional observational study that observed the management recommendations for LBP provided in primary care using a simulated patient approach. Trained actors requested an over-the-counter medicine or asked for management advice for 1 of 2 simulated patient scenarios: nonspecific LBP (NSLBP) or vertebral compression fracture. Visits were audiorecorded to allow data capture, validation, and review. We evaluated concordance with key recommendations provided in evidence-based LBP guidelines on pain medicines, patient self-care advice, and referral. Visits were conducted across 534 pharmacies comprising 336 nonspecific scenarios and 198 fracture scenarios. Recommendations for pain medicines, but not patient self-care advice and referral, were typically consistent with guidelines. For the NSLBP scenario, the concerns were infrequent provision of reassurance of favorable outcome (8%), advice to stay active (5%), advice to avoid bed rest (0%), advice to use superficial heat (24%), and excessive endorsement of referral (57.4%) and imaging (22.7%). For the fracture scenario, the concerns were a low rate of prompt medical referrals (50.0%) and low endorsement of rest (1.0%).


      We observed primary care that aligned closely with some aspects, but was at odds with other aspects, of evidence-based LBP guidelines. Problems included inadequate self-care advice and failing to appropriately recommend imaging or prompt medical review when indicated. These results can inform implementation strategies to improve primary care management of LBP.

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        • Abdel Shaheed C.
        • Maher C.G.
        • Williams K.A.
        • McLachlan A.J.
        Interventions available over the counter and advice for acute low back pain: systematic review and meta-analysis.
        J Pain. 2014; 15: 2-15
        • Abdel Shaheed C.
        • Maher C.
        • Williams K.
        • McLachlan A.J.
        Participation of pharmacists in clinical trial recruitment for low back pain.
        Int J Clin Pharm. 2014; 36: 986-994
        • Abdel Shaheed C.
        • Maher C.
        • Mak W.
        • Williams K.
        • McLachlan A.J.
        The effects of educational interventions on pharmacists’ knowledge, attitudes and beliefs towards low back pain.
        Int J Clin Pharm. 2015; 37: 616-625
        • Australian Acute Musculoskeletal Pain Guidelines Group
        Evidence-Based Management of Acute Musculoskeletal Pain–A Guide for Clinicians.
        Australian Academic Press, Bowen Heads, Qld2004
        • Benrimoj S.I.
        • Gilbert A.L.
        • de Almeida Neto A.C.
        • Kelly F.
        National implementation of standards of practice for non-prescription medicines in Australia.
        Pharm World Sci. 2009; 31: 230-237
        • Berger K.
        • Eickhoff C.
        • Schulz M.
        Counselling quality in community pharmacies: implementation of the pseudo customer methodology in Germany.
        J Clin Pharm Ther. 2005; 30: 45-57
        • Bishop P.B.
        • Wing P.C.
        Compliance with clinical practice guidelines in family physicians managing worker's compensation board patients with acute lower back pain.
        Spine J. 2003; 3: 442-450
        • Buckeridge D.
        • Huang A.
        • Hanley J.
        • Kelome A.
        • Reidel K.
        • Verma A.
        • Winslade N.
        • Tamblyn R.
        Risk of injury associated with opioid use in older adults.
        J Am Geriatr Soc. 2010; 58: 1664-1670
        • Buer N.
        • Linton S.J.
        Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population.
        Pain. 2002; 99: 485-491
        • Chou R.
        • Fu R.
        • Carrino J.A.
        • Deyo R.A.
        Imaging strategies for low-back pain: systematic review and meta-analysis.
        Lancet. 2009; 373: 463-472
        • Chua S.S.
        • Ramachandran C.D.
        • Paraidathathu T.T.
        Response of community pharmacists to the presentation of back pain: a simulated patient study.
        Int J Pharm Pract. 2006; 14: 171-178
        • Dahm K.T.
        • Brurberg K.G.
        • Jamtvedt G.
        • Hagen K.B.
        Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica.
        Cochrane Database Syst Rev. 2010; : CD007612
        • Dey P.
        • Simpson C.W.R.
        • Collins S.I.
        • Hodgson G.
        • Dowrick C.F.
        • Simison A.J.
        • Rose M.J.
        Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial.
        Br J Gen Pract. 2004; 54: 33-37
        • Downie A.
        • Williams C.M.
        • Henschke N.
        • Hancock M.J.
        • Ostelo R.W.
        • de Vet H.C.
        • Macaskill P.
        • Irwig L.
        • van Tulder M.W.
        • Koes B.W.
        • Maher C.G.
        Red flags to screen for malignancy and fracture in patients with low back pain: systematic review.
        BMJ. 2013; 347: f7095
        • Drake C.
        Human factors: a vital component in product development and launch.
        Int J Med Market. 2002; 3: 7-19
        • Elfving B.
        • Andersson T.
        • Grooten W.J.
        Low levels of physical activity in back pain patients are associated with high levels of fear-avoidance beliefs and pain catastrophizing.
        Physiother Res Int. 2007; 12: 14-24
        • Engers A.J.
        • Wensing M.
        • van Tulder M.W.
        • Timmermans A.
        • Oostendorp R.A.
        • Koes B.W.
        • Grol R.
        Implementation of the Dutch low back pain guideline for general practitioners: a cluster randomized controlled trial.
        Spine. 2005; 30: 559-600
        • Evans D.W.
        • Breen A.C.
        • Pincus T.
        • Sim J.
        • Underwood M.
        • Vogel S.
        • Foster N.E.
        The effectiveness of a posted information package on the beliefs and behavior of musculoskeletal practitioners: the UK Chiropractors, Osteopaths, and Musculoskeletal Physiotherapists Low Back Pain Management (COMPLeMENT) randomized trial.
        Spine. 2010; 35: 858-866
        • Frankel B.S.
        • Moffett J.K.
        • Keen S.
        • Jackson D.
        Guidelines for low back pain: changes in GP management.
        Fam Pract. 1999; 16: 216-222
        • Gonzalez-Urzelai V.
        • Palacio-Elua L.
        • Lopez-de-Munain J.
        Routine primary care management of acute low back pain: adherence to clinical guidelines.
        Eur Spine J. 2003; 12: 589-594
        • Henschke N.
        • Maher C.G.
        • Refshauge K.M.
        • Herbert R.D.
        • Cumming R.G.
        • Bleasel J.
        • York J.
        • Das A.
        • McAuley J.H.
        Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain.
        Arthritis Rheum. 2009; 60: 3072-3080
        • Iedema J.
        Cautions with codeine.
        Aust Prescr. 2011; 34: 133-135
        • Koes B.W.
        • van Tulder M.
        • Lin C.W.
        • Macedo L.G.
        • McAuley J.
        • Maher C.
        An updated overview of clinical guidelines for the management of non-specific low back pain in primary care.
        Eur Spine J. 2010; 19: 2075-2094
        • Maher C.
        • Williams C.
        • Lin C.
        • Latimer J.
        Managing low back pain in primary care.
        Aust Prescr. 2011; 34: 128-132
        • Norris P.T.
        Purchasing restricted medicines in New Zealand pharmacies: results from a ‘‘mystery shopper’’ study.
        Pharm World Sci. 2002; 24: 149-153
        • Pharmaceutical Society of Australia
        National Competency Standards Framework for Pharmacists in Australia.
        2010 (Available at:) (Accessed September 19, 2015)
      1. Pharmacy Access/Remoteness Index of Australia (PHARIA) Available at: Accessed July 7, 2014.

        • Pincus T.
        • Burton A.K.
        • Vogel S.
        • Field A.P.
        A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain.
        Spine. 2002; 27: E109-E120
      2. Relief for your aching back. Consumer reports US findings. Available at: Accessed June 12, 2014.

        • Roumie C.L.
        • Griffin M.R.
        Over-the-counter analgesics in older adults–call for improved labelling and consumer education.
        Drugs Aging. 2004; 21: 485-498
      3. Royal College of General Practitioners. Clinical Guidelines for the Management of Acute Low Back Pain. London, Royal College of General Practitioners, 1996 and 1999.

        • Schectman J.M.
        • Schroth W.S.
        • Verme D.
        • Voss J.D.
        Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain.
        J Gen Intern Med. 2003; 18: 773-780
        • Schers H.
        • Braspenning J.
        • Drijver R.
        • Wensing M.
        • Grol R.
        Low back pain in general practice: reported management and reasons for not adhering to the guidelines in the Netherlands.
        Br J Gen Pract. 2000; 50: 640-644
        • Schneider C.R.
        • Everett A.W.
        • Geelhoed E.
        • Kendall P.A.
        • Clifford R.M.
        Measuring the assessment and counseling provided with the supply of nonprescription asthma reliever medication: a simulated patient study.
        Ann Pharmacother. 2009; 43: 1512-1518
        • Silcock J.
        • Moffett J.K.
        • Edmondson H.
        • Waddell G.
        • Burton A.K.
        Do community pharmacists have the attitudes and knowledge to support evidence based self-management of low back pain?.
        BMC Musculoskelet Disord. 2007; 8: 10
        • Van Tulder M.
        • Becker A.
        • Bekkering T.
        • Breen A.
        • Del Real M.T.
        • Hutchinson A.
        • Koes B.
        • Laerum E.
        • Malmivaara A.
        COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care. Chapter 3: European guidelines for the management of acute nonspecific low back pain in primary care.
        Eur Spine J. 2006; 15: S169-S191
        • Vella E.
        • Azzopardi L.M.
        • Zarb-Adami M.
        • Serracino-Inglott A.
        Development of protocols for the provision of headache and back-pain treatments in Maltese community pharmacies.
        Int J Pharm Pract. 2009; 17: 269-274
        • Verbeek J.
        • Sengers M.J.
        • Riemens L.
        • Haafkens J.
        Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies.
        Spine. 2004; 29: 2309-2318
        • Walker B.F.
        • Muller R.
        • Grant W.D.
        Low back pain in Australian adults: the economic burden.
        Asia Pac J Public Health. 2003; 15: 79-87
        • Walker B.F.
        • Muller R.
        • Grant W.D.
        Low back pain in Australian adults. health provider utilization and care seeking.
        J Manipulative Physiol Ther. 2004; 27: 327-335
        • Walker B.
        • French S.
        • Page M.
        • O’Connor D.
        • McKenzie J.
        • Berringer K.
        • Murphy K.
        • Keating J.L.
        • Michie S.
        • Francis J.J.
        • Green S.E.
        Management of people with acute low-back pain: a survey of Australian chiropractors.
        Chiropr Man Therap. 2011; 19: 29
        • Watson M.C.
        • Hart J.
        • Johnston M.
        • Bond C.M.
        Exploring the supply of non-prescription medicines from community pharmacies in Scotland.
        Pharm World Sci. 2008; 30: 526-535
        • Werner J.B.
        • Benrimoj S.I.
        Audio taping simulated patient encounters in community pharmacy to enhance the reliability of assessments.
        Am J Pharm Educ. 2008; 72: 136
        • Williams C.M.
        • Maher C.G.
        • Hancock M.J.
        • McAuley J.H.
        • McLachlan A.J.
        • Britt H.
        • Fahridin S.
        • Harrison C.
        • Latimer J.
        Low back pain and best practice care a survey of general practice physicians.
        Arch Intern Med. 2010; 170: 271-277
        • Williams C.M.
        • Maher C.G.
        • Latimer J.
        • McLachlan A.J.
        • Hancock M.
        • Day R.
        • Lin C.W.
        Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial.
        Lancet. 2014; 384: 1586-1596