BMJ 1996;312:485-488 (24 February)

General practice

General practitioners' management of acute back pain: a survey of reported practice compared with clinical guidelines

Paul Little, GP Wellcome training fellow,a Lisa Smith, research physiotherapist,b Ted Cantrell, consultant rheumatologist,b Judith Chapman, lecturer in physiotherapy,c John Langridge, manager of physiotherapy services,b Ruth Pickering, lecturer in medical statistics d

a Primary Care, Faculty of Medicine, Health, and Biological Sciences, University of Southampton, Southampton SO16 5ST, b Southampton Hospitals NHS Trust, Southampton SO16 6YD, c School of Occupational Therapy and Physiotherapy, University of Southampton, Southampton SO17 1BJ, d Medical Statistics and Computing, University of Southampton, Southampton SO16 6YD

Correspondence to: Dr Little.

Abstract

Objective: To compare general practitioners' reported management of acute back pain with "evidence based" guidelines for its management.
Design: Confidential postal questionnaire.
Setting: One health district in the South and West region.
Subjects: 236 general practitioners; 166 (70%) responded.
Outcome measures: Examination routinely performed, "danger" symptoms and signs warranting urgent referral, advice given, and satisfaction with management.
Results: A minority of general practitioners do not examine reflexes routinely (27%, 95% confidence interval 20% to 34%), and a majority do not examine routinely for muscle weakness or sensation. Although most would refer patients with danger signs, some would not seek urgent advice for saddle anaesthesia (6%, 3% to 11%), extensor plantar response (45%, 37% to 53%), or neurological signs at multiple levels (15%, 10% to 21%). A minority do not give advice about back exercises (42%, 34% to 49%), fitness (34%, 26% to 41%), or everyday activities. A minority performed manipulation (20%) or acupuncture (6%). One third rated their satisfaction with management of back pain as 4 out of 10 or less.
Conclusions: The management of back pain by general practitioners does not match the guidelines, but there is little evidence from general practice for many of the recommendations, including routine examination, activity modification, educational advice, and back exercises. General practitioners need to be more aware of danger symptoms and of the benefits of early mobilisation and possibly of manipulation for persisting symptoms. Guidelines should reference each recommendation and discuss study methodology and the setting of evidence.

Key messages

  • Key messages

  • It is unclear, however, to what extent these guidelines are followed in general practice, where most episodes are managed, and where most cases settle within a few weeks

  • The study shows that management of back pain by general practitioners does not match the guidelines, in that most do not routinely perform some recommended examinations and several do not give advice about exercise or everyday activities. In particular some neglect danger signs

  • Many of the guidelines' recommendations, however, are not based on evidence from general practice. More research based in general practice is needed, and guidelines should clearly reference the evidence for each recommendation


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