Highlights
- •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.
Abstract
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%).
Perspective
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.
Key words
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References
- Interventions available over the counter and advice for acute low back pain: systematic review and meta-analysis.J Pain. 2014; 15: 2-15
- Participation of pharmacists in clinical trial recruitment for low back pain.Int J Clin Pharm. 2014; 36: 986-994
- The effects of educational interventions on pharmacists’ knowledge, attitudes and beliefs towards low back pain.Int J Clin Pharm. 2015; 37: 616-625
- Evidence-Based Management of Acute Musculoskeletal Pain–A Guide for Clinicians.Australian Academic Press, Bowen Heads, Qld2004
- National implementation of standards of practice for non-prescription medicines in Australia.Pharm World Sci. 2009; 31: 230-237
- Counselling quality in community pharmacies: implementation of the pseudo customer methodology in Germany.J Clin Pharm Ther. 2005; 30: 45-57
- 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
- Risk of injury associated with opioid use in older adults.J Am Geriatr Soc. 2010; 58: 1664-1670
- Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population.Pain. 2002; 99: 485-491
- Imaging strategies for low-back pain: systematic review and meta-analysis.Lancet. 2009; 373: 463-472
- Response of community pharmacists to the presentation of back pain: a simulated patient study.Int J Pharm Pract. 2006; 14: 171-178
- Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica.Cochrane Database Syst Rev. 2010; : CD007612
- Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial.Br J Gen Pract. 2004; 54: 33-37
- Red flags to screen for malignancy and fracture in patients with low back pain: systematic review.BMJ. 2013; 347: f7095
- Human factors: a vital component in product development and launch.Int J Med Market. 2002; 3: 7-19
- 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
- Implementation of the Dutch low back pain guideline for general practitioners: a cluster randomized controlled trial.Spine. 2005; 30: 559-600
- 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
- Guidelines for low back pain: changes in GP management.Fam Pract. 1999; 16: 216-222
- Routine primary care management of acute low back pain: adherence to clinical guidelines.Eur Spine J. 2003; 12: 589-594
- 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
- Cautions with codeine.Aust Prescr. 2011; 34: 133-135
- 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
- Managing low back pain in primary care.Aust Prescr. 2011; 34: 128-132
- Purchasing restricted medicines in New Zealand pharmacies: results from a ‘‘mystery shopper’’ study.Pharm World Sci. 2002; 24: 149-153
- National Competency Standards Framework for Pharmacists in Australia.2010 (Available at:) (Accessed September 19, 2015)
Pharmacy Access/Remoteness Index of Australia (PHARIA) Available at: http://www.adelaide.edu.au/apmrc/research/projects/pharia/pharia-info.html Accessed July 7, 2014.
- A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain.Spine. 2002; 27: E109-E120
Relief for your aching back. Consumer reports US findings. Available at: http://www.consumerreports.org/cro/2013/01/relief-for-your-aching-back/index.htm Accessed June 12, 2014.
- Over-the-counter analgesics in older adults–call for improved labelling and consumer education.Drugs Aging. 2004; 21: 485-498
Royal College of General Practitioners. Clinical Guidelines for the Management of Acute Low Back Pain. London, Royal College of General Practitioners, 1996 and 1999.
- Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain.J Gen Intern Med. 2003; 18: 773-780
- 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
- Measuring the assessment and counseling provided with the supply of nonprescription asthma reliever medication: a simulated patient study.Ann Pharmacother. 2009; 43: 1512-1518
- Do community pharmacists have the attitudes and knowledge to support evidence based self-management of low back pain?.BMC Musculoskelet Disord. 2007; 8: 10
- 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
- Development of protocols for the provision of headache and back-pain treatments in Maltese community pharmacies.Int J Pharm Pract. 2009; 17: 269-274
- Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies.Spine. 2004; 29: 2309-2318
- Low back pain in Australian adults: the economic burden.Asia Pac J Public Health. 2003; 15: 79-87
- Low back pain in Australian adults. health provider utilization and care seeking.J Manipulative Physiol Ther. 2004; 27: 327-335
- Management of people with acute low-back pain: a survey of Australian chiropractors.Chiropr Man Therap. 2011; 19: 29
- Exploring the supply of non-prescription medicines from community pharmacies in Scotland.Pharm World Sci. 2008; 30: 526-535
- Audio taping simulated patient encounters in community pharmacy to enhance the reliability of assessments.Am J Pharm Educ. 2008; 72: 136
- Low back pain and best practice care a survey of general practice physicians.Arch Intern Med. 2010; 170: 271-277
- Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial.Lancet. 2014; 384: 1586-1596
Article info
Publication history
Published online: October 05, 2015
Accepted:
September 24,
2015
Received in revised form:
September 20,
2015
Received:
February 18,
2015
Footnotes
This research received funding from the Pharmacy Guild of Australia. C.A.S. is supported by an Australian Postgraduate Research Award. C.G.M. is supported by a National Health and Medical Research Council Senior Fellowship. C.G.M. and A.J.M. are investigators on the PACE (Paracetamol for Low Back Pain) trial (http://www.anzctr.org.au/ACTRN12609000966291.aspx), which was jointly funded by project grant 570883 from the National Health and Medical Research Council and GlaxoSmithKline.
Supplementary data accompanying this article are available online at www.jpain.org and www.sciencedirect.com.
Identification
Copyright
© 2016 American Pain Society. Published by Elsevier Inc. All rights reserved.
