What is usual care for low back pain? A systematic review of healthcare provided to patients with low back pain in family practice and emergency departments

Key points

1. 01Only around 20% of family practice patients received guideline-recommended education, reassurance, or exercise advice
2. 02Around 1 in 4 family practice patients and 1 in 3 emergency department patients were referred for lumbar imaging
3. 03Opioids were prescribed to up to 30% of family practice patients and up to 60% of emergency department patients
4. 04NSAIDs, the recommended first-line medication, were prescribed to only 35-40% of family practice patients and 50% of emergency department patients
5. 05High-quality evidence came mainly from the USA, Australia, and a small number of European countries, limiting global generalisability

How it was conducted

Design

Systematic review of observational studies (prospectively registered: PROSPERO CRD42018070241)

Search period

Studies reporting data from January 2000 to May 2019; databases searched: PubMed, EMBASE, CINAHL

Included studies

26 studies - 18 in family practice, 8 in emergency departments

Participants

194,388 patients with low back pain across all included studies

Data sources

Routinely collected medical records and hospital/insurance administrative databases (20 of 26 studies)

Quality assessment

12 studies rated high quality (meeting 4 of 5 methodological criteria); synthesis prioritised high-quality estimates

What they found

• Education or reassurance was provided to 21% and 23% of family practice patients in the two high-quality studies reporting this outcome; exercise advice was given to 19% of patients
• X-ray referral: 16-20% of family practice patients; 30% of emergency department patients
• CT scan referral: 2-6% in family practice; 6% in emergency departments
• MRI referral: less than 1% to 5% in family practice; 3% to 25% in emergency departments
• Any imaging referral: 11-26% in family practice (three studies); 29% and 37% in emergency departments (two studies)
• NSAIDs prescribed to 36-37% of family practice patients and 50% of emergency department patients
• Opioids (including combination analgesics) prescribed to 5-31% of family practice patients; two emergency department studies reported rates of 17% and 61%
• Muscle relaxants prescribed to 1-8% of family practice patients and 42% of emergency department patients
• Physiotherapy referral: 14-27% of family practice patients (three studies)
• Surgical consult referral: up to 10% from family practice; 8% from emergency departments

Limitations

• High-quality evidence came from only a small number of western countries (USA, Australia, Netherlands, Italy, Spain), limiting generalisability to other healthcare systems
• Assessments and advice are poorly captured in routine administrative data, so these components are likely underestimated
• Included studies span approximately 15 years and the synthesis does not account for changes in practice patterns over time
• Studies focused on physician care only and findings may not apply to physiotherapists, chiropractors, or other first-contact providers

Why it matters

For patients

Most patients seeing a doctor for back pain are not getting the recommended advice to stay active and self-manage, and are instead more likely to receive imaging or opioid prescriptions that guidelines caution against.

For clinicians

There is a substantial gap between guideline recommendations and actual practice in both family medicine and emergency settings, with opioid and imaging overuse and advice underuse being the main targets for quality improvement.

For readers

This review quantifies usual care benchmarks from nearly 200,000 patients and highlights the need for both system-level policy changes and better clinical data infrastructure to audit and improve low back pain management.