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Background Patients presenting to Emergency Department (ED) with non-specific low back pain can receive more unnecessary, intensive and costly care than is recommended. The COVID-19 pandemic has provided an unprecedented opportunity to examine how health systems prioritise necessary care that provides clear benefits to patients. The purpose of this study was to examine the impact of COVID-19 on care of low back pain in the ED. Methods We performed a retrospective analysis of electronic medical record data on care for low back pain from three public hospitals in Sydney. We included patients diagnosed with spinal conditions who presented between March and May in 2019 and in 2020. Outcomes were the total number of patients presenting with spinal conditions to ED, the proportion diagnosed with non-specific low back pain, and the proportion receiving potentially unnecessary aspects of care (ambulance use, imaging, opioids, hospital admissions). We calculated relative risk with 95% CIs and examined plots with locally weighted smoothed curves. Results Presentations for spinal conditions over a three-month period to three EDs reduced from 694 in 2019 to 475 in 2020 (31% reduction, 95% CI = 26%–37%). The proportion of patients diagnosed with non-specific low back pain (83% in 2019 vs 86% in 2020), or receiving potentially unnecessary care were similar in 2019 and 2020 (Imaging = 25% vs 25%; Opioids = 54% vs 56%; Admitted = 18% vs 20%; pathology test = 24% vs 23%). The proportion of patients arriving by ambulance was higher during the pandemic; 29% in 2019 vs 41% in 2020 (RR = 1.39, 95% CI = 1.19–1.63). Conclusions ED presentations for low back pain associated with spinal conditions decreased substantially during the COVID-19 pandemic. Use of potentially unnecessary aspects of care did not change or increased during the pandemic.

Refereed/Peer-reviewed A new wave of treatments has emerged to target nervous system alterations and mal-adaptive conceptualizations about pain for chronic low back pain. The acceptability of these treatments is still uncertain. We conducted a qualitative study alongside a randomized controlled trial to identify perceptions of facilitators or barriers to participation in a non-pharmacological intervention that resulted in clinically meaningful reductions across 12 months for disability compared to a sham intervention. We conducted semi-structured interviews with participants from the trial’s active arm after they completed the 12-week program. We included a purposeful sample (baseline and clinical characteristics) (n = 20). We used reflexive thematic analysis informed by the Theoretical Framework of Acceptability for health care interventions. We identified positive and negative emotional/cognitive responses associated with treatment acceptability and potential efficacy, including emotional support, cognitive empowerment, readiness for self-management, and acceptance of face-to-face and online components designed to target the brain. These findings suggest the importance of psychoeducation and behavior change techniques to create a positive attitude towards movement and increase the perception of pain control; systematic approaches to monitor and target misconceptions about the interventions during treatment; and psychoeducation and behavior change techniques to maintain the improvements after the cessation of formal care. Perspective: This article presents the experiences of people with chronic low back pain participating in a new non-pharmacological brain-targeted treatment that includes face-to-face and self-directed approaches. The facilitators and barriers of the interventions could potentially inform adaptations and optimization of treatments designed to target the brain to treat chronic low back pain.

This observational study evaluated people's attitudes towards educational statements and tested whether this predicted intention to self-manage low back pain (LBP).People with or without LBP who were over 18-years of age and fluent in written English were recruited. Participants completed an online survey asking demographic questions and questions on the presence or absence of LBP, its duration and intensity. We assessed attitude toward educational statements and conducted linear regression analyses to investigate the relationship between attitude toward each statement and intention to self-manage.We recruited 656 participants, n=345(53.6%), with LBP of varying duration. On average, participants had a positive attitude toward all statements except one; participants with chronic LBP had a negative attitude toward a statement relating to the cause of LBP. The effect of attitude on intention to self-manage was dependent on whether someone had LBP and for how long. For example, increased intention to self-manage was predicted by a positive attitude toward educational statements related to staying active [β= 0.22 (CI 0.11 to 0.33] in participants without pain, statements about reassurance [β=0.33 (CI 0.16 to 0.49] for participants with acute or subacute LBP, and statements about the severity of back pain [β= 0.25 (CI 0.18 to 0.33] for participants with chronic LBP.We noted differences in attitude toward educational messages and individuals' intention to self-manage LBP depending on pain duration. Self-management could be encouraged with specific reassurance in people with acute or subacute LBP and education about severity in people with chronic LBP.

Question Does feeling reassured after a consultation reduce future disability or healthcare use in people with acute low back pain (LBP)? Design Mediation analysis of a randomised, sham-controlled trial. Participants Two hundred and two people with acute LBP at above average risk (high risk) of developing chronic LBP. Intervention All participants received guideline-based care from their usual clinician. Participants received two additional 1-hour sessions of patient education focused on emphasising the benign nature of LBP or sham patient education that included active listening only. Outcome measures The two primary outcomes for this study were self-reported disability and healthcare use. The mediator was feeling reassured that LBP was not caused by serious illness. Results Data from 194 (96%) participants and 178 (88%) participants were included in the analysis for disability and healthcare use outcome models, respectively. Feeling reassured did not mediate the effect of the intervention on disability (indirect effect −0.23, 95% CI −0.71 to 0.18) or healthcare use (indirect effect 0.00, 95% CI −0.04 to 0.04). Patient education intervention increased feeling reassured (1.14 points, 95% CI 0.43 to 1.85) compared with sham patient education. However, the mediator (ie, feeling reassured) did not reduce disability (−0.20 points, 95% CI −0.58 to 0.19) or healthcare use (OR 1.09, 95% CI 0.98 to 1.21). Conclusion Feeling reassured after a consultation did not lead to improvements in disability and healthcare use for people with acute LBP. Clinicians should reflect on the time that they allocate to reassuring their patients and consider reallocating time to other aspects of the consultation that could reduce disability and future healthcare use. Trial registration ACTRN12612001180808, study protocol https://osf.io/4tfaz/ .

IntroductionSocial media provide promising contemporary platforms for sharing public health information with a broad audience. Before implementation, testing social media campaigns that are intended to engage audiences and initiate behaviour change is necessary. This trial aims to investigate the effectiveness of a public health campaign to increase people’s confidence in becoming more active despite low back pain in comparison with no intervention.Methods and analysisThis is an online randomised controlled trial with two intervention groups and one control group in a 1:1:1 allocation. People over 18 years of age and fluent in English will be recruited via social media advertising. We developed a social media-based public health campaign to support recommendations for managing low back pain. The interventions are two videos. Participants in the control group will be asked questions about low back pain but will not view either video intervention. The primary outcome will be item 10 of the Pain Self-Efficacy Questionnaire, which asks participants to rate how confident they would feel to gradually become more active despite pain ranging from 0 (not at all confident) to 6 (completely confident). This outcome will be measured immediately in all participant groups. We will compare group mean of the three arms of the trial using univariate analyses of variance.Ethics and disseminationThis trial has been prospectively registered with the Australian New Zealand Clinical Trials Registry. We obtained ethical approval from our institutions Human Research Ethics Committee before data collection. We will publish the results in a peer-reviewed medical journal and on institution websites.Trial registration numberAustralian New Zealand Clinical Trials Registry (ACTRN12622000466741).

Background Community awareness of the harms of overdiagnosis remains low. Objective To evaluate community responses to a public health campaign designed for health service waiting rooms that focuses on the harms of unnecessary diagnostic imaging for low back pain. Methods We conducted two focus groups of 19 community members with or without low back pain in Sydney, Australia. This study formed the fourth and final stage of the development process of a public health campaign: (a) initial design, (b) expert review and revision, (c) online experiment and (d) community views & revision. We evaluated reactions to components of the campaign that included digital posters and an information leaflet using strong imagery and messaging about the risk of overdiagnosis. We conducted a qualitative thematic analysis to identify main themes. Results Community members reacted with surprise, initial mistrust, and occasionally anger towards imagery and messaging that suggested diagnostic imaging tests could be unnecessary and harmful. With further reflection and discussion, and after reading longer format information about overdiagnosis, the participants found some of the messages informative and useful. Participants appeared to gain a better understanding of the concept of overdiagnosis and the importance of not rushing to imaging. Conclusions Public health campaigns including posters and leaflets displayed in waiting rooms could raise awareness about overuse of diagnostic imaging and the harms of overdiagnosis more broadly. However, negative reactions are possible and must be managed carefully. Patient or public contribution We involved a community participation manager who provided advice on the focus group discussion guide, participant recruitment and manuscript presentation.

We aimed to determine, in those who present to the ED with low back pain (LBP): (i) the prevalence of four key diagnostic categories, (ii) trends in lumbar imaging from 2015 to 2019 and (iii) the effect of a new model of care on lumbar imaging in the ED.We conducted a retrospective analysis of routinely collected medical data of four tertiary hospitals in Sydney, Australia. We analysed ED presentations for LBP between January 2012 and October 2019. Outcomes were the prevalence of four key diagnostic categories of LBP and use of lumbar imaging. We examined trends in lumbar imaging over time and used interrupted time series analysis to determine the impact of model of care implementation on imaging use.There were 31 168 presentations for LBP of which 64.5% were non-specific LBP, 27.2% were problems beyond the spine, 5.3% were LBP with neurological signs and 2.3% were serious spinal conditions. 28.9% received lumbar imaging; use did not change substantially between 2012 and 2019. Patients diagnosed with serious spinal conditions were more likely to receive imaging (59%) than those diagnosed with non-specific LBP (29%). Implementation of a state-wide model of care in November 2016 did not appear to influence imaging use.Most presentations to the ED for LBP are for non-specific LBP. Around 2% will have specific spinal pathology. Use of imaging in those diagnosed with non-specific LBP remains high and was unaffected by implementation of a state-wide model of care.

To compare and contrast the diagnostic codes for spinal causes of low back pain (LBP) in 3 disease classification systems (International Classification of Diseases [ICD]-10, International Classification of Primary Care [ICPC]-2 PLUS and Systematized Nomenclature of Medicine Clinical Terms - Australia [SNOMED CT-AU]) and consider how well they are aligned with the diagnostic approach recommended in contemporary clinical practice guidelines for LBP.This was a descriptive study which included 3 disease classification systems: ICD-10, ICPC-2 PLUS and SNOMED CT-AU. Two independent authors extracted relevant LBP codes from each system and mapped the codes to 3 guideline-endorsed categories of spine-related diagnoses for LBP (specific spinal pathology, radicular syndromes, and non-specific LBP) and the various clinical conditions (sub-categories) within each of the 3 categories.ICD-10, ICPC-2 PLUS, and SNOMED CT-AU had 126, 118 and 100 codes for LBP, respectively. All systems provided codes that would cover the 3 guideline-endorsed categories of spine-related diagnoses for LBP. On the basis of contemporary guidelines, the authors developed lists of discrete sub-categories of specific spinal pathology (56 sub-categories), radicular syndromes (7 sub-categories), and non-specific LBP (10 sub-categories). Each of the classification systems was then mapped against these sub-categories to tally redundancy and determine exhaustiveness. However, no system covered all 73 sub-categories of LBP, and within each system, there was substantial redundancy with up to 22 codes for the same clinical condition.LBP diagnostic codes used in popular disease classification systems are out of touch with current approaches to diagnosis, as reflected in contemporary LBP guidelines. Our findings suggest these disease classification systems need revision, but precisely how they should be revised is unclear.

Refereed/Peer-reviewed Introduction: Chronic low back pain (CLBP) is pain that has persisted for greater than three months. It is common and burdensome and represents a significant proportion of primary health presentations. For the majority of people with CLBP, a specific nociceptive contributor cannot be reliably identified, and the pain is categorised as 'non-specific'. Exercise therapy is recommended by international clinical guidelines as a first-line treatment for non-specific CLBP. Aim: This comprehensive review aims to synthesise and appraise the current research to provide practical, evidence-based guidance concerning exercise prescription for non-specific CLBP. We discuss detailed initial assessment and being informed by patient preferences, values, expectations, competencies and goals. Methods: We searched the Cochrane Database of Systematic Reviews, PubMed and the Physiotherapy Evidence Database (PEDro) using broad search terms from January 2000 to March 2021, to identify the most recent clinical practice guidelines, systematic reviews and randomised controlled trials on exercise for CLBP. Results/Discussion: Systematic reviews show exercise is effective for small, short-term reductions in pain and disability, when compared with placebo, usual care, or waiting list control, and serious adverse events are rare. A range of individualised or group-based exercise modalities have been demonstrated as effective in reducing pain and disability. Despite this consensus, controversies and significant challenges remain. Conclusion: To promote recovery, sustainable outcomes and self-management, exercise can be coupled with education strategies, as well as interventions that enhance adherence, motivation and patient self-efficacy. Clinicians might benefit from intentionally considering their own knowledge and competencies, potential harms of exercise and costs to the patient. This comprehensive review provides evidence-based practical guidance to health professionals who prescribe exercise for people with non-specific CLBP.

Background Few studies have investigated the effects of waiting room communication strategies on health-care behavior. Objective We aimed to determine the effect of a waiting room communication strategy, designed to raise awareness of potential harms of unnecessary imaging, on lumbar imaging rates in the emergency department (ED). Methods We conducted a controlled experimental study with a replicated time series design. The design included a 6-week run-in time. Following this there were alternating 1-week intervention and control periods. The intervention group received a communication strategy describing the potential harms of unnecessary imaging for low back pain, shown on a 55” LCD screen positioned in the ED waiting room. The communication strategy was designed by a creative innovation agency and included five digital posters and a patient leaflet. The control group received standard messaging for the waiting room at the time, shown on the same 55” LCD screen, and access to the patient leaflet. The primary outcome was the number and proportion of people presenting to ED with low back pain who received at least one lumbar imaging test, measured using routinely collected ED data. Secondary patient-reported outcomes (patient satisfaction and awareness of campaign messages) were collected from a sample of people presenting for any condition who responded to a text-message-based survey. Results For the imaging outcome, 337 people presenting to ED with low back pain were included over a 4-month period (intervention n = 99; control n = 238). All had available data on lumbar imaging. Use of lumbar imaging was 25% in those exposed to the communication strategy [95% confidence interval (CI) = 18% to 35%] compared with 29% in those exposed to the standard waiting room messaging [95% CI = 23% to 35%; odds ratio (OR) = 0.83, 95% CI = 0.49 to 1.41]. For the patient-reported outcomes, 349 patients presenting to ED for any condition responded to the survey (intervention n = 170; control n = 179; response rate = 33%). There was uncertain evidence that the intervention increased awareness of the communication strategy leaflet (OR = 2.00, 95% CI = 0.90 to 4.47). Other measures did not suggest between-group differences in patient satisfaction or awareness of the campaign messages. Conclusion A communication strategy displayed in the ED waiting room may slightly reduce the proportion of patients with low back pain who receive lumbar imaging, although there is uncertainty due to imprecision. The campaign did not appear to increase awareness of campaign messages or affect patient satisfaction in a sample of patients presenting to the ED for any reason. Larger studies should investigate whether simple, low-cost waiting room communication strategies can raise awareness of unnecessary healthcare and influence health-care quality. Trial registration ACTRN12620000300976, 05/03/2020

Introduction Clinician time and resources may be underutilised if the treatment they offer does not match patient expectations and attitudes. We developed a questionnaire (AxEL-Q) to guide clinicians toward elements of first-line care that are pertinent to their patients with low back pain. Methods We used guidance from the COSMIN consortium to develop the questionnaire and evaluated it in a sample of people with low back pain of any duration. Participants were recruited from the community, were over 18 years and fluent in English. Statements that represented first-line care were identified. Semantic scales were used to measure attitude towards these statements. These items were combined to develop the questionnaire draft. Construct validity was evaluated with exploratory factor analysis and hypotheses testing, comparing to the Back Beliefs Questionnaire and modified Pain Self-Efficacy Questionnaire. Reliability was evaluated and floor and ceiling effects calculated. Results We recruited 345 participants, and had complete data for analysis for 313 participants. The questionnaire draft was reduced to a 3-Factor questionnaire through exploratory factor analysis. Factor 1 comprised 9 items and evaluated Attitude toward staying active, Factor 2 comprised 4 items and evaluated Attitude toward low back pain being rarely caused by a serious health problem, Factor 3 comprised 4 items and evaluated Attitude toward not needing to know the cause of back pain to manage it effectively. There was a strong inverse association between each factor and the Back Beliefs Questionnaire and a moderate positive association with the modified Pain Self-Efficacy Questionnaire. Each independent factor demonstrated acceptable internal consistency; Cronbach α Factor 1 = 0.92, Factor 2 = 0.91, Factor 3 = 0.90 and adequate interclass correlation coefficients; Factor 1 = 0.71, Factor 2 = 0.73, Factor 3 = 0.79. Conclusion This study demonstrates acceptable construct validity and reliability of the AxEL-Q, providing clinicians with an insight into the likelihood of patients following first-line care at the outset.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of spinal cord stimulators for people with low back pain, with or without leg pain.

Introduction There is a common belief that patients presenting to emergency departments have more severe pain levels and functional limitations than those who are seen in general practice. The aim of this systematic review was to compare pain and disability levels of patients with acute low back pain presenting to general practice vs those presenting to emergency departments. Methods Electronic searches were conducted in MEDLINE, EMBASE, and CINAHL from database inception to February 2019. Observational studies including patients with acute non-specific low back pain presenting to emergency departments and/or general practice were eligible. Pain and/or disability scores expressed on a 0–100 scale were the primary outcomes. Risk of bias was evaluated with a validated tool for observational studies, and the overall quality of evidence was assessed with Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Meta-analysis with random effects and meta-regression were used to test for differences between the two settings. Results We included 12 records reporting results for 10 unique studies with a total of 6,999 participants from general practice (n = 6) and emergency departments (n = 4). There was low-quality evidence (downgraded for indirectness and inconsistency) that patients presenting to emergency departments had higher pain scores than those in general practice, with a mean difference of 17.3 points (95% confidence interval: 8.8 to 25.9 on a 0–100 scale). Similarly, there was low-quality evidence (downgraded for indirectness and inconsistency) that patients presenting to emergency departments had higher disability scores than those in general practice (mean difference: 21.7; 95% confidence interval: 4.6 to 38.7 on a 0–100 scale). Conclusion Patients with acute non-specific low back pain presenting to emergency departments may report higher levels of pain and disability than those seen in general practice.

Background Imaging for low back pain is widely regarded as a target for efforts to reduce low-value care. Objective We aimed to estimate the prevalence of the overuse and underuse of lumbar imaging in patients presenting with low back pain to the emergency department (ED). Methods This was a retrospective chart review study of five public hospital EDs in Sydney, Australia, in 2019–20. We reviewed the clinical charts of consecutive adult patients who presented with a complaint of low back pain and extracted clinical features relevant to a decision to request lumbar imaging. We estimated the proportion of encounters where a decision to request lumbar imaging was inappropriate (overuse) or where a clinician did not request an appropriate and informative lumbar imaging test when indicated (underuse). Results Six hundred and forty-nine patients presented with a complaint of low back pain, of which 158 (24.3%) were referred for imaging. Seventy-nine (12.2%) had a combination of features suggesting that lumbar imaging was indicated according to clinical guidelines. The prevalence of overuse and underuse of lumbar imaging was 8.8% (57 of 649 cases, 95% CI 6.8–11.2%) and 4.3% (28 of 649 cases, 95% CI 3.0–6.1%), respectively. Thirteen cases were classified as underuse because the patients were referred for uninformative imaging modalities (e.g. referred for radiography for suspected cauda equina syndrome). Conclusion In this study of emergency care, there was evidence of not only overuse of lumbar imaging but also underuse through failure to request lumbar imaging when indicated or referral for an uninformative imaging modality. These three issues seem more important targets for quality improvement than solely focusing on overuse.

Patient education is recommended as first-line care for low back pain (LBP), although its efficacy for providing clinically meaningful reductions in disability has been questioned. One way to improve treatment effects is to identify and improve targeting of treatment mechanisms. We conducted a pre-planned causal mediation analysis of a randomized, placebo-controlled trial investigating the effectiveness of patient education for patients with acute LBP. 202 patients who had fewer than six-weeks’ duration of LBP and were at high-risk of developing chronic LBP completed two, one-hour treatment sessions of either intensive patient education, or placebo patient education. 189 participants provided data for the outcome self-reported disability at three-months and the mediators, pain self-efficacy, pain catastrophizing, and back beliefs at one-week post treatment. This causal mediation analysis found that pain catastrophizing (mediated effect, -0.64; 95% Confidence Interval [CI], -1.31 to -0.15) and back beliefs (mediated effect, -0.51; 95% CI, -1.15 to -0.02) partly explained the effect of patient education on disability but pain self-efficacy did not (mediated effect, -0.40; 95% CI -1.13 to 0.28). Considering the mediator-outcome relationship, patient education would need to induce an 8 point difference on the pain self-efficacy questionnaire (0-60); an 11 point difference on the back beliefs questionnaire (9-45); and a 21 point difference on the pain catastrophizing scale (0-52) to achieve a minimally clinically important difference of 2 points on the Roland Morris Disability Questionnaire (0-24). PERSPECTIVE Understanding the mechanisms of patient education can inform how this treatment can be adapted to provide clinically meaningful reductions in disability. Our findings suggest that adapting patient education to better target back beliefs and pain self-efficacy could result in clinically meaningful reductions in disability whereas the role of pain catastrophizing in acute LBP is less clear.

Objective Low back pain is the leading contributor to the global disability burden. The Global Spine Care Initiative (GSCI) recommend patient-centred care to stem the cost of low back pain. One way to enhance patient-centred care is by better understanding what is relevant for people with low back pain. Exploring social media posts about low back pain could offer this insight and provide valuable information for health care professionals to facilitate active participation in patient-centred care. Methods We used an inductive content analysis method. In the form of social media posts, data on Twitter and Instagram were collected from June to August 2018. The posts were geo-targeted to Australia. We recorded the number of status broadcasts that contained a low back pain keyword and responses. We developed a codebook to describe the data and applied it to identify low back pain themes. Results We analysed 768 posts containing 457 status broadcasts and 311 responses. Almost half (49%) of status broadcasts about low back pain seemed to seek validation. Expressing sympathy (31%) was the most common response to a status broadcast about low back pain. There were no public responses to 76% of status broadcasts about low back pain. Our analysis yielded two core themes, “hear my pain” and “I feel for you". Conclusions Posts about low back pain on social media often seem to suggest that the person posting is seeking validation. Responses typically express sympathy or a shared experience; yet, there is no response to most social media posts about low back pain.

ObjectiveDelayed prescribing is a promising strategy to manage patient requests for unnecessary tests and treatments. The purpose of this study was to explore general practitioner (GP) and patient views of three communication tools (Overdiagnosis Leaflet, Dialogue Sheet and ‘Wait-and-see’ Note) to support delayed prescribing of diagnostic imaging.DesignQualitative study.SettingPrimary and emergency care in Sydney, Australia.Participants16 GPs and 14 patients with recent episode of low back pain.OutcomeViews on the tools to delay diagnostic imaging for low back pain. Data were collected using a combination of focus groups and individual interviews.AnalysisTwo researchers independently performed a thematic analysis, and the author team reviewed and refined the analysis.ResultsGP participants responded positively to the Overdiagnosis Leaflet. The Dialogue Sheet and ‘Wait-and-see’ Note raised several concerns about patient pushback, adding to time pressure and being overwhelmed with hard-to-find paper resources. GPs preferred to communicate verbally the reasons to delay an imaging test. For patients, the reactions to the tools were more positive. Patients valued written information and a signed agreement to delay the test. However, patients expressed that a strong desire for diagnostic imaging would likely over-ride any effect of written advice to delay the test. The term ‘false alarm’ to describe overdiagnosis was poorly understood by patients.ConclusionsGPs and patients agreed that a leaflet about overdiagnosis could support a delayed prescribing approach to imaging for low back pain. The Dialogue Sheet and ‘Wait-and-see’ Note were acceptable to patients but not to GPs.

ObjectiveOveruse of diagnostic imaging for patients with low back pain remains common. The underlying beliefs about diagnostic imaging that could drive overuse remain unclear. We synthesised qualitative research that has explored clinician, patient or general public beliefs about diagnostic imaging for low back pain.DesignA qualitative evidence synthesis using a thematic analysis.MethodsWe searched MEDLINE, EMBASE, CINAHL, AMED and PsycINFO from inception to 17 June 2019. Qualitative studies that interviewed clinicians, patients and/or general public exploring beliefs about diagnostic imaging for low back pain were included. Four review authors independently extracted data and organised these according to themes and subthemes. We used the Critical Appraisal Skills Programme tool to critically appraise included studies. To assess confidence in review findings, we used the GRADE-Confidence in the Evidence from Reviews of Qualitative Research method.ResultsWe included 69 qualitative studies with 1747 participants. Key findings included: Patients and clinicians believe diagnostic imaging is an important test to locate the source of low back pain (33 studies, high confidence); patients with chronic low back pain believe pathological findings on diagnostic imaging provide evidence that pain is real (12 studies, moderate confidence); and clinicians ordered diagnostic imaging to reduce the risk of a missed diagnosis that could lead to litigation, and to manage patients’ expectations (12 studies, moderate confidence).ConclusionClinicians and patients can believe that diagnostic imaging is an important tool for locating the source of non-specific low back pain. Patients may underestimate the harms of unnecessary imaging tests. These beliefs could be important targets for intervention.PROSPERO registration numberCRD42017076047.

BackgroundOveruse of lumbar imaging in the Emergency Department is a well-recognised healthcare challenge. Studies to date have not provided robust evidence that available interventions can reduce overuse. For an intervention aimed at reducing imaging to be effective, insight into how both patients and clinicians view lumbar imaging tests is essential.AimTo explore factors that might influence overuse of lumbar imaging in the Emergency Department.MethodsParticipants were recruited from three hospitals in Sydney, Australia between April and August 2019. We conducted focus groups and/or interviews with 14 patients and 12 clinicians. Sessions were audio-recorded and transcribed verbatim. Data were analysed using framework analysis by a team of four researchers with diverse backgrounds.ResultsPatients described feeling that the decision about lumbar imaging was made by their Emergency Department clinician and reported little involvement in the decision-making process. Other potential drivers of lumbar imaging overuse from the patients’ perspective were strong expectations for lumbar imaging, a reluctance to delay receiving a diagnosis, and requirements from third parties (eg, insurance companies) to have imaging. Emergency Department clinicians suggested that the absence of an ongoing therapeutic relationship, and the inability to manage perceived patient pressure could drive overuse of lumbar imaging. Suggested protective factors included: involving patients in the decision, ensuring clinicians have the ability to explain the reasons to avoid imaging and collaborative approaches to care both within the Emergency Department and with primary care.Conclusion and key findingsWe found several factors that could contribute to overuse of lumbar imaging in the Emergency Department. Solutions to overuse of lumbar imaging in the Emergency Department could include: (1) strategies to involve patients in decisions about imaging; (2) training and support to provide thorough and well explained clinical assessment for low back pain; and (3) systems that support collaborative approaches to care.

Objective To review and assess the methodological quality of randomised controlled trials that test physical therapy interventions for low back pain. Study Design and Setting Systematic review of trials of physical therapy interventions to prevent or treat low back pain (of any duration or type) in participants of any age indexed on the Physiotherapy Evidence Database (PEDro). Existing PEDro scale ratings were used to evaluate methodology quality. Results This review identified 2215 trials. The majority of trials were for adults (n=2136, 96.4%), low back pain without specific aetiology (n=1863, 84.1%), and chronic duration (n=947, 42.8%). The quality of trials improved over time, however most were at risk of bias. Less than half of the trials concealed allocation to intervention (n=813, 36.7%), used intention-to-treat principles (n=778, 35.1%), blinded assessors (n=810, 36.6%), participants (n=174, 7.9%) and therapists (n=39, 1.8%). These findings did not vary by type of therapy. Conclusion The majority of trials that test physical therapy interventions for low back pain have methodological limitations that could bias treatment effect estimates. Greater attention to simple methodological features, such as allocation concealment and the reporting of intention-to-treat effects, would improve the quality of trials testing physical therapy interventions for low back pain.

Objectives It has been hypothesised that attentional bias to environmental threats can contribute to persistent pain. It is unclear whether people with acute low back pain (LBP) have an attentional bias to environmental threats. We investigated if attentional bias of threat related words is different in people with acute LBP and pain-free controls. Methods People with acute LBP and pain-free people completed a free viewing eye tracking task. Participants were simultaneously presented with two words, a threat related word and a neutral control word. Threat related words were general threat, affective pain and sensory pain. We conducted linear mixed models to detect differences between acute LBP and pain-free participants on five eye tracking outcome measures (dwell time, first fixation, latency to first fixation, first run dwell time and number of fixations). We calculated absolute reliability, (standard error of measure), and relative reliability (intraclass correlation coefficients [ICC 2,1]) for each eye tracking outcome measures. Results We recruited 65 people with acute LBP and 65 pain-free controls. Participants with acute LBP had a higher proportion of fixations towards the affective pain words (M=0.5009, 95% CI=0.4941, 0.5076) than the pain-free controls had (M=0.4908, 95% CI=0.4836, 0.4979), mean between group difference = −0.0101, 95% CI [−0.0198, −0.0004], p=0.0422. There was no difference between acute LBP and pain-free controls for the remaining eye tracking outcome measures (all p>0.05). The only outcome measure that had an ICC of more than 0.7 was the latency to first fixation (affective pain words ICC=0.73, general threat words ICC=0.72). Conclusions When compared with pain-free controls, people with acute LBP looked more often at affective pain words relative to neutral control words. This may indicate a form of engagement bias for people with acute LBP. Attentional bias was not consistent across outcome measures or word groups. Further research is needed to investigate the potential role of attentional bias in the development of persistent pain.

Background Shared decision-making can reduce the uptake of some unnecessary tests and procedures. Although awareness of shared decision-making is increasing, overuse of diagnostic tests for common clinical conditions, such as low back pain, remains high. Recent public health campaigns, such as the ‘Choosing Wisely’ Initiative, attempt to persuade consumers to avoid unnecessary tests, rather than provide neutral information on benefits and harms. It is unclear whether persuasive information materials can influence perceptions of imaging tests more than neutral materials, and whether such public health approaches could have unintended consequences (e.g. decision regret). Objective To evaluate the effect of different types of information leaflets on public perceptions of imaging for low back pain. Design Randomised online experiment. Setting Community (online) and 1 tertiary hospital. Participants 360 members of the general public (recruited via Facebook) with or without low back pain, who have been asked to imagine they have experienced a severe episode of low back pain. Recruitment of the general public sample is due for completion in March 2019. We are also purposively sampling patients attending the back-pain outpatient clinic of a large tertiary hospital, who are being interviewed about the leaflets. Intervention We are randomising participants to read one of the three leaflets on their computer screen, tablet, or smart phone: (i) Control leaflet: guideline information (ii) Neutral leaflet: balanced information on benefits/harms of imaging (iii) Persuasive leaflet: information biased towards harms of imaging. Immediately after reading the leaflet participants complete an online survey. Outcome measures Intention to undergo imaging for low back pain (primary outcome measure). Secondary outcome measures include beliefs about necessity of imaging, usefulness of leaflet, knowledge, worry, harms, satisfaction with decision, decision regret. Results The study is underway and due for completion in April 2019. We will present results in full at the conference. Conclusion This study will be the first to compare the impact of information leaflets designed for a public health campaign about unnecessary imaging of low back pain. The data will inform future development of public health resources and shared decision-making interventions.

Objectives In 2018 clinicians provided diagnostic imaging tests to almost half of all patients who present to a NSW ED with low back pain. It is unclear how many of these tests were unnecessary. We aimed to determine whether a system to estimate unnecessary imaging rates could be developed and validated in NSW Hospital EDs. Method Two clinician researchers will screen the clinical charts of people who presented to a NSW ED for low back pain over a one month period. The researchers will read the clinical notes, reason for imaging request, ED discharge letter, ED imaging report, and hospital admission report to judge appropriateness. Using a checklist of guideline indications for urgent imaging, researchers will code each imaging order as being ‘appropriate,’ ‘potentially appropriate’ ‘unnecessary,’ or ‘unable to determine appropriateness.’ To determine reliability of the coding system we will calculate agreement (Kappa).To detect a kappa >=0.6 with 90% power, two raters will review a minimum 255 clinical charts each. This estimate assumes a two-tailed test with a null value of kappa=0.4, proportion of positive ratings =0.3 (ie we expect ∼30% lumbar imaging tests will be rated as ‘appropriate’). Results Results will be presented at the conference. Conclusions This study will be the first to estimate the rate of unnecessary diagnostic imaging for low back pain in NSW EDs based on comprehensive case note reviews.

Background: Marketing communication and brand identity is a fundamental principle of advertising and end-user engagement. Health researchers have begun to apply this principle to trial recruitment in primary care. The aim of this study was to evaluate whether a Teaser Campaign using a series of postcards in advance of a conventional mail-out increases the number of primary care clinics that engage with a clinical trial. Methods: Embedded randomised recruitment trial across primary care clinics (general practitioners and physiotherapists) in the Sydney metropolitan area. Clinics in the Teaser Campaign group received a series of branded promotional postcards in advance of a standard letter inviting them to participate in a clinical trial. Clinics in the Standard Mail group did not receive the postcards. Results: From a total of 744 clinics that were sent an invitation letter, 46 clinics in the Teaser Campaign group and 40 clinics in the Standard Mail group responded (11.6% total response rate). There was no between-group difference in the odds of responding to the invitation letter (odds ratio = 1.18, 95% confidence interval = 0.75–1.85, p = 0.49). For physiotherapy clinics and general practice clinics, the odds ratios were 1.43 (confidence interval = 0.82–2.48, p = 0.21) and 0.77 (confidence interval = 0.34–1.75, p = 0.54), respectively. Conclusion: A Teaser Campaign using a series of branded promotional postcards did not improve clinic engagement for a randomised controlled trial in primary care.

© 2016 Elsevier Ireland Ltd Objective Professional appearance is easily modifiable, and might alter the effects of a clinical encounter. We aimed to determine whether professional attire influences a patient's perception of treatment credibility. Methods We performed a single-blind randomized controlled study on 128 patients with acute non-specific low back pain who were about to receive treatment in primary care. The treating clinician was randomly allocated to wear formal attire (experimental condition) or casual attire (control condition) to the consultation. Clinicians provided a standardized briefing on the rationale behind the patient's forthcoming treatment. Treatment credibility (Credibility and Expectancy Questionnaire) was assessed immediately after this briefing. Results All patients received the experimental or control condition as allocated and provided complete primary outcome data. Formal attire had no effect on perceived treatment credibility (Mean difference between groups 1.2 [95%CI-1.1 to 3.5]). Age was the only significant predictor of treatment credibility; older patients rated treatment credibility higher (Beta = 0.16 [95%CI 0.08 to 0.24]). Conclusion In a trial setting, whether or not a clinician is formally dressed has no effect on perceptions of treatment credibility in patients with acute low back pain. Practice implication Clinicians should dress comfortably without fear of losing credibility.

Low back pain is the leading cause of years lived with disability globally. In 2018, an international working group called on the World Health Organization to increase attention on the burden of low back pain and the need to avoid excessively medical solutions. Indeed, major international clinical guidelines now recognize that many people with low back pain require little or no formal treatment. Where treatment is required the recommended approach is to discourage use of pain medication, steroid injections and spinal surgery, and instead promote physical and psychological therapies. Many health systems are not designed to support this approach. In this paper we discuss why care for low back pain that is concordant with guidelines requires system-wide changes. We detail the key challenges of low back pain care within health systems. These include the financial interests of pharmaceutical and other companies; outdated payment systems that favour medical care over patients' self-management; and deep-rooted medical traditions and beliefs about care for back pain among physicians and the public. We give international examples of promising solutions and policies and practices for health systems facing an increasing burden of ineffective care for low back pain. We suggest policies that, by shifting resources from unnecessary care to guideline-concordant care for low back pain, could be cost-neutral and have widespread impact. Small adjustments to health policy will not work in isolation, however. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change.Les lombalgies sont la principale cause d'années de vie vécues avec une incapacité dans le monde. En 2018, un groupe de travail international a invité l'Organisation mondiale de la Santé à attirer l'attention sur la charge que représentent les lombalgies et sur la nécessité d'éviter le recours excessif aux solutions médicales. En effet, selon les dernières recommandations cliniques internationales, de nombreux cas de lombalgie ne nécessitent pas ou peu de traitement formel. Lorsqu'un traitement est requis, il est recommandé de limiter la prise d'analgésiques, les injections de stéroïdes et la chirurgie rachidienne, et d'encourager plutôt les thérapeutiques physiques et psychologiques. Très souvent, les systèmes de santé ne sont pas conçus pour appliquer cette approche. Dans cet article, nous abordons les raisons pour lesquelles un changement des systèmes s'impose si l'on veut prendre en charge les lombalgies suivant les recommandations. Nous détaillons les principales difficultés de la prise en charge des lombalgies dans le cadre des systèmes de santé. Il s'agit notamment des intérêts financiers des laboratoires pharmaceutiques, entre autres; des systèmes de paiement obsolètes qui privilégient la prise en charge médicale à l'autogestion par les patients; et de croyances et traditions médicales profondément ancrées parmi les médecins et la population. Nous donnons des exemples internationaux de solutions, de politiques et de pratiques prometteuses pour les systèmes de santé confrontés de plus en plus souvent à une prise en charge inefficace des lombalgies. Nous suggérons des politiques qui, sans incidence sur les coûts, en transférant les ressources allouées aux soins inutiles vers des soins conformes aux recommandations, pourraient avoir un impact considérable. De petits ajustements des politiques de santé ne suffiront cependant pas. Les systèmes des milieux professionnels, les cadres juridiques, les croyances personnelles, les politiques et le contexte sociétal global dans lequel s'inscrit la santé devront également changer.El dolor lumbar es la causa principal de vivir con discapacidad durante años en todo el mundo. En 2018, un grupo de trabajo internacional pidió a la Organización Mundial de la Salud que prestara más atención a la carga del dolor lumbar y a la necesidad de evitar soluciones excesivamente médicas. De hecho, las principales directrices clínicas internacionales reconocen ahora que muchas personas con dolor lumbar requieren poco o ningún tratamiento formal. Cuando se requiere tratamiento, el enfoque recomendado es desalentar el uso de analgésicos, inyecciones de esteroides y cirugía de la columna vertebral y, en su lugar, promover las terapias físicas y psicológicas. Muchos sistemas de salud no están diseñados para apoyar este enfoque. En este documento, se expone por qué el cuidado del dolor lumbar de acuerdo con las directrices requiere cambios en todo el sistema. Se detallan los retos clave de la atención del dolor lumbar en los sistemas de salud. Estos incluyen los intereses financieros de las compañías farmacéuticas y de otro tipo, los sistemas de pago obsoletos que favorecen la atención médica por encima del autocuidado de los pacientes, así como las tradiciones y las creencias médicas profundamente arraigadas sobre la atención del dolor de espalda entre los médicos y el público general. Se presentan ejemplos internacionales de soluciones prometedoras y de políticas y prácticas para los sistemas de salud que se enfrentan a una carga cada vez mayor de la atención ineficaz para el dolor lumbar. Se sugieren políticas que, al desplazar los recursos de la atención innecesaria a la atención acorde con las directrices para el dolor lumbar, podrían ser neutras en cuanto a costes y tener un impacto generalizado. Sin embargo, los pequeños ajustes en la política sanitaria no funcionarán de forma aislada. Los sistemas del lugar de trabajo, los marcos jurídicos, las creencias personales, la política y el contexto social general en el que vivimos la salud también tendrán que cambiar.آلام أسفل الظهر هي السبب الرئيسي على مستوى العالم لقضاء سنوات من الحياة في ظل الإعاقة. في عام 2018، طالبت مجموعة عمل دولية منظمة الصحة العالمية بزيادة الاهتمام بأعباء آلام أسفل الظهر، والحاجة إلى تجنب المحاليل الطبية بشكل مفرط. والواقع أن المبادئ التوجيهية السريرية الدولية الرئيسية الحالية تدرك أن العديد من الأشخاص الذين يعانون من آلام أسفل الظهر يحتاجون إلى القليل من العلاج الرسمي، أو لا يحتاجون إليه. عندما يكون العلاج مطلوبًا، فإن الأسلوب الموصى به هو الابتعاد عن استخدام دواء للألم، وحقن الستيرويد، وجراحة العمود الفقري. وبدلا من ذلك يتم الترويج للعلاجات البدنية والنفسية. إلا أن العديد من النظم الصحية ليست مصممة لدعم هذا الأسلوب. نناقش في هذا البحث لماذا تتطلب رعاية آلام أسفل الظهر المتوافقة مع الإرشادات، تغييرات في النظام بالكامل. نحن نتناول بالتفصيل التحديات الرئيسية للعناية بآلام أسفل الظهر في النظم الصحية. وهي تشمل المصالح المالية لشركات الأدوية وغيرها من الشركات؛ مثل أنظمة الدفع القديمة التي تفضل الرعاية الطبية على الإدارة الذاتية للمرضى؛ والتقاليد والمعتقدات الطبية الراسخة بشأن رعاية آلام الظهر بين الأطباء والعامة. نحن نعطي أمثلة دولية للحلول والسياسات والممارسات الواعدة للنظم الصحية التي تواجه عبئاً متزايدا من الرعاية غير الفعالة لآلام أسفل الظهر. كما نقترح سياسات يمكنها - من خلال تحويل الموارد من الرعاية غير الضرورية إلى الرعاية المتوافقة مع المبادئ التوجيهية لآلام أسفل الظهر - أن تكون محايدة من حيث التكلفة ولها تأثير واسع الانتشار. إلا أن عمليات الضبط البسيطة في السياسة الصحية لن تعمل بمفردها. حيث سيحتاج أيضاً للتغيير كل من أنظمة مكان العمل، وأطر العمل القانونية، والمعتقدات الشخصية، والسياسات، والطابع المجتمعي العام الذي نواجهه في الصحة.腰痛是与全球残疾人士相伴数年的一项主要病因。2018 年，某国际工作小组呼吁世卫组织加强对腰痛负担的关注，并尽力避免过度医疗。事实上，主要国际临床指南现已认可腰痛患者只需极少治疗或无需正式治疗。使用止痛药、注射类固醇和进行腰椎手术并非值得鼓励的推荐疗法，相应地，患者应改善生理和心理状态。但许多卫生系统并非为支持此疗法设计。在本文中，我们讨论了符合指南的腰痛护理为何需要进行系统性变革，并详述了卫生系统中腰痛护理的关键挑战，包括制药公司与其它公司的经济利益；过时的医疗保险偿付系统更倾向于让患者接受医疗服务而非自我管理；以及医生与公众对腰背痛护理的医疗传统和信仰早已根深蒂固。我们为因腰痛护理无效而面临沉重负担的卫生系统提供了一些国际案例，包含颇有前景的解决方案、政策和实践。我们建议施行成本适中、有广泛影响的政策，将不必要的护理资源转换成符合指南的腰痛护理。然而，卫生政策方面的微小调整无法单独起作用，这同时也需要工作场所制度、法律框架、个人信仰、政治以及我们所期望的卫生系统整体社会环境的相应改变。.Боль в поясничной области является основной причиной многолетней инвалидности во всем мире. В 2018 году международная рабочая группа призвала Всемирную организацию здравоохранения уделять больше внимания бремени боли в поясничной области и необходимости исключения чрезмерного медицинского вмешательства. В связи с этим основные международные клинические рекомендации на настоящий момент признают, что большинству пациентов с болями в поясничной области практически не требуется формального лечения. В случае если лечение необходимо, рекомендуемый подход не советует использовать обезболивающие препараты, инъекции стероидов и операции на позвоночнике, предлагая вместо этого активно использовать физическую терапию и психотерапию. Многие системы здравоохранения не в состоянии поддерживать данный подход. В этой статье авторы обсуждают причины, по которым рекомендуемая медицинская помощь при боли в поясничной области требует реформирования всей системы здравоохранения. Авторы подробно описывают основные проблемы лечения боли в поясничной области в рамках различных систем здравоохранения. Среди них следует отметить финансовые интересы фармацевтических и других компаний; устаревшие платежные системы, делающие упор на оказание медицинской помощи вместо обучения пациента методам самопомощи; глубоко укоренившиеся традиции и убеждения у врачей и широкой общественности относительно медицинской помощи при боли в поясничной области. Авторы приводят примеры возможных международных решений, а также политики и практические подходы для систем здравоохранения, сталкивающихся с растущим бременем неэффективной помощи при боли в поясничной области. В статье предлагаются процедуры и методики, которые могут не требовать дополнительных расходов и иметь широкомасштабное воздействие благодаря переключению ресурсов с оказания ненужной медицинской помощи на согласующуюся с рекомендациями помощь при боли в поясничной области. Однако небольшие корректировки политики в области здравоохранения не будут эффективными, если они будут проводиться изолированно друг от друга. Необходимо также преобразование систем на рабочих местах, правовых основ, личных убеждений, политик и общественного контекста, связанных со здравоохранением.

Background. Musculoskeletal conditions are leading causes of disability. Management options are plentiful, but the current evidence base suggests many are ineffective or unproven. Online decision aids can help support patients make informed health care choices. However, there are little data on the quality of online decision aids for common musculoskeletal conditions such as knee or low back pain. Purpose. To identify all publicly available online decision aids for knee osteoarthritis and low back pain and evaluate them against the International Patient Decision Aids Standards Inventory (IPDASi). Data Sources. Google Australia. Study selection. Two reviewers independently screened websites for inclusion and assessed the quality of included online decision aids between April and May 2018. Included online decision aids were free, provided information about knee osteoarthritis or low back pain, and written in English. Online decision aids that required payment, targeted health professionals, addressed rheumatoid arthritis, or addressed a screening decision were excluded. Data Extraction. IPDASi Version 4. Data Synthesis. Twenty-five online decision aids were identified: 15 knee osteoarthritis and 10 low back pain. Only 3 online decision aids (12%) provided a “wait-and-see” option. Nineteen (75%) met IPDASi criteria to be considered a decision aid and 3 (12%) met IPDASi criteria to state that the online decision aid was unbiased. Limitations. Dynamic nature of Google searches may not be replicable easily. Conclusions. Few good-quality online decision aids are available for people with knee osteoarthritis or low back pain. Most online decision aids failed to explicitly provide a wait-and-see option, suggesting a bias toward intervention. These online decision aids would benefit from explicitly highlighting a wait-and-see option to support informed choice.

© 2018 2018 American Medical Association. All rights reserved. Importance: Many patients with acute low back pain do not recover with basic first-line care (advice, reassurance, and simple analgesia, if necessary). It is unclear whether intensive patient education improves clinical outcomes for those patients already receiving first-line care. Objective: To determine the effectiveness of intensive patient education for patients with acute low back pain. Design, Setting, and Participants: This randomized, placebo-controlled clinical trial recruited patients from general practices, physiotherapy clinics, and a research center in Sydney, Australia, between September 10, 2013, and December 2, 2015. Trial follow-up was completed in December 17, 2016. Primary care practitioners invited 618 patients presenting with acute low back pain to participate. Researchers excluded 416 potential participants. All of the 202 eligible participants had low back pain of fewer than 6 weeks' duration and a high risk of developing chronic low back pain according to Predicting the Inception of Chronic Pain (PICKUP) Tool, a validated prognostic model. Participants were randomized in a 1:1 ratio to either patient education or placebo patient education. Interventions: All participants received recommended first-line care for acute low back pain from their usual practitioner. Participants received additional 2 × 1-hour sessions of patient education (information on pain and biopsychosocial contributors plus self-management techniques, such as remaining active and pacing) or placebo patient education (active listening, without information or advice). Main Outcomes and Measures: The primary outcome was pain intensity (11-point numeric rating scale) at 3 months. Secondary outcomes included disability (24-point Roland Morris Disability Questionnaire) at 1 week, and at 3, 6, and 12 months. Results: Of 202 participants randomized for the trial, the mean (SD) age of participants was 45 (14.5) years and 103 (51.0%) were female. Retention rates were greater than 90% at all time points. Intensive patient education was not more effective than placebo patient education at reducing pain intensity (3-month mean [SD] pain intensity: 2.1 [2.4] vs 2.4 [2.2]; mean difference at 3 months, -0.3 [95% CI, -1.0 to 0.3]). There was a small effect of intensive patient education on the secondary outcome of disability at 1 week (mean difference, -1.6 points on a 24-point scale [95% CI, -3.1 to -0.1]) and 3 months (mean difference, -1.7 points, [95% CI, -3.2 to -0.2]) but not at 6 or 12 months. Conclusions and Relevance: Adding 2 hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes. Clinical guideline recommendations to provide complex and intensive support to high-risk patients with acute low back pain may have been premature. Trial Registration: Australian Clinical Trial Registration Number: 12612001180808.

Objectives(1) Describe the evolution of guideline-endorsed red flags for fracture in patients presenting with low back pain; (2) evaluate agreement between guidelines; and (3) evaluate the extent to which recommendations are accompanied by information on diagnostic accuracy of endorsed red flags.DesignSystematic review.Data sourcesMEDLINE and PubMed, PEDro, CINAHL and EMBASE electronic databases. We also searched in guideline databases, including theNational Guideline ClearinghouseandCanadian Medical Association Infobase.Eligibility criteria for selecting studiesEvidence-based clinical practice guidelines.Data extractionTwo review authors independently extracted the following data: health professional association or society producing guideline, year of publication, the precise wording of endorsed red flag for vertebral fracture, recommendations for diagnostic workup if fracture is suspected, if the guidelines substantiate the recommendation with citation to a primary diagnostic study or diagnostic review, if the guideline provides any diagnostic accuracy data.Results78 guidelines from 28 countries were included. A total of 12 discrete red flags were reported. The most commonly recommended red flags were older age, use of steroids, trauma and osteoporosis. Regarding the evolution of red flags, older age, trauma and osteoporosis were the first red flags endorsed (in 1994); and previous fracture was the last red flag endorsed (in 2003). Agreement between guidelines in endorsing red flags was only fair; kappa=0.32. Only 9 of the 78 guidelines substantiated their red flag recommendations by research and only nine provided information on diagnostic accuracy.Summary/conclusionThe number of red flags endorsed in guidelines to screen for fracture has risen over time; most guidelines do not endorse the same set of red flags and most recommendations are not supported by research or accompanied by diagnostic accuracy data.

Made available in DSpace on 2018-12-11T17:21:22Z (GMT). No. of bitstreams: 0 Previous issue date: 2018-07-03 Objective: The aim of this study was to provide an overview of the recommendations regarding the diagnosis and treatment contained in current clinical practice guidelines for patients with non-specific low back pain in primary care. We also aimed to examine how recommendations have changed since our last overview in 2010. Method: The searches for clinical practice guidelines were performed for the period from 2008 to 2017 in electronic databases. Guidelines including information regarding either the diagnosis or treatment of non-specific low back pain, and targeted at a multidisciplinary audience in the primary care setting, were considered eligible. We extracted data regarding recommendations for diagnosis and treatment, and methods for development of guidelines. Results: We identified 15 clinical practice guidelines for the management of low back pain in primary care. For diagnosis of patients with non-specific low back pain, the clinical practice guidelines recommend history taking and physical examination to identify red flags, neurological testing to identify radicular syndrome, use of imaging if serious pathology is suspected (but discourage routine use), and assessment of psychosocial factors. For treatment of patients with acute low back pain, the guidelines recommend reassurance on the favourable prognosis and advice on returning to normal activities, avoiding bed rest, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and weak opioids for short periods. For treatment of patients with chronic low back pain, the guidelines recommend the use of NSAIDs and antidepressants, exercise therapy, and psychosocial interventions. In addition, referral to a specialist is recommended in case of suspicion of specific pathologies or radiculopathy or if there is no improvement after 4 weeks. While there were a few discrepancies across the current clinical practice guidelines, a substantial proportion of recommendations was consistently endorsed. In the current review, we identified some differences compared to the previous overview regarding the recommendations for assessment of psychosocial factors, the use of some medications (e.g., paracetamol) as well as an increasing amount of information regarding the types of exercise, mode of delivery, acupuncture, herbal medicines, and invasive treatments. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.] Departamento de Fisioterapia Faculdade de Ciências e Tecnologia Universidade Estadual Paulista (UNESP) Sydney School of Public Health Faculty of Medicine and Health University of Sydney Institute for Musculoskeletal Health Sydney Local Health District Department of Physical Therapy Universidade Federal de Minas Gerais (UFMG) Department of General Practice Institute for Community Medicine University Medicine Greifswald Department of Health Sciences Faculty of Sciences and Amsterdam Movement Sciences Institute Vrije Universiteit Department of General Practice Erasmus Medical Center, P.O. Box 2040 Center for Muscle and Health University of Southern Denmark Departamento de Fisioterapia Faculdade de Ciências e Tecnologia Universidade Estadual Paulista (UNESP)

Objectives Low back pain cannot be overdiagnosed, at least not in the narrow sense of the word. However, it is a common symptom, and one that is often given a diagnostic label (slipped disc, pinched nerve, instability, arthritis, degeneration, and so on), despite there being no reliable way of determining the pain source in most cases. Once the symptom is labelled, however, the consequences begin to resemble those of overdiagnosis: many will experience no clinical benefit from receiving a diagnostic label, but will feel less well because of it, and are more likely to undergo costly, invasive treatments with questionable efficacy. We will present our current understanding of overdiagnosis of low back pain, discuss how low back pain might differ from other well-known examples of overdiagnosis, and detail efforts from within our research group and beyond to develop and evaluate solutions. Method If one were to consider the broader definitions of overdiagnosis proposed by Carter et al. (BMJ 2015;350:h869), healthcare for low back pain would have examples abound: disease mongering (‘Pain as the 5th vital sign’ campaign by US Veteran’s Affairs), overutilisation (spinal injections, opioids), overdetection (diagnostic imaging), overtreatment (spinal fusion surgery, early physiotherapy), and false positives (red flags for serious pathology). In 2013 Americans spent US$81.6 billion on care for low back pain. How did we end up here? Results Unlike other well-known examples, overdiagnosis of low back pain appears to have little to do with altering disease definitions or thresholds, or providing screening programs for the healthy. Some people with low back pain may receive no diagnosis but are overtreated. Conclusions We argue that many of the problems with overdiagnosis and overtreatment of low back pain arise because people enter a health system that is set up to encourage inappropriate care and discourage appropriate care.

Objective‘Nudges’ are subtle cognitive cues thought to influence behaviour. We investigated whether embedding nudges in a general practitioner (GP) clinical decision support display can reduce low-value management decisions .MethodsAustralian GPs completed four clinical vignettes of patients with low back pain. Participants chose from three guideline-concordant and three guideline-discordant (low-value) management options for each vignette, on a computer screen. A 2×2 factorial design randomised participants to two possible nudge interventions: ‘partition display’ nudge (low-value options presented horizontally, high-value options listed vertically) or ‘default option’ nudge (high-value options presented as the default, low-value options presented only after clicking for more). The primary outcome was the proportion of scenarios where practitioners chose at least one of the low-value care options.Results120 GPs (72% male, 28% female) completed the trial (n=480 vignettes). Participants using a conventional menu display without nudges chose at least one low-value care option in 42% of scenarios. Participants exposed to the default option nudge were 44% less likely to choose at least one low-value care option (OR 0.56, 95%CI 0.37 to 0.85; p=0.006) compared with those not exposed. The partition display nudge had no effect on choice of low-value care (OR 1.08, 95%CI 0.72 to 1.64; p=0.7). There was no interaction between the nudges (OR 0.94, 95% CI 0.41 to 2.15; p=0.89).InterpretationA default option nudge reduced the odds of choosing low-value options for low back pain in clinical vignettes. Embedding high value options as defaults in clinical decision support tools could improve quality of care. More research is needed into how nudges impact clinical decision-making in different contexts.

Low back pain causes more disability worldwide than any other health condition.1 Although many people self-manage their condition without needing to seek care,2 low back pain is the second most frequent symptom to prompt attendance in general practice after the common cold.3 Most low back pain is ‘non-specific’ meaning there is no identifiable spinal pathology. While the available evidence suggests a limited role for medicines in the management of an acute episode of non-specific low back pain, medicine prescription remains almost routine.4 Many patients with persisting symptoms also continue to take medicines long-term despite the low likelihood of ongoing benefits. We suggest a different approach that emphasises selective prescribing, and discontinuing medicines that are no longer of benefit, for patients with non-specific low back pain. Recent guidelines indicate a reduced role for medicines in the management of non-specific low back pain. The 2017 Danish Guideline does not recommend any medicine.5 The 2016 UK guideline from the National Institute for Health and Care Excellence only recommends non-steroidal anti-inflammatory drugs (NSAIDs) and ‘weak’ opioids.6 The 2017 US guideline from the American College of Physicians (ACP) makes a similar recommendation and includes the addition of skeletal muscle relaxants for acute non-specific low back pain (ie, pain for

KEY POINTS Low-back pain is the leading cause of disability worldwide.[1][1] It is the second most common symptom-related reason for seeking care from a primary care physician.[2][2] In Australia, low-back pain is the number one cause of early retirement and income poverty.[3][3] Although most

Delivering efficient and effective healthcare is crucial for a condition as burdensome as low back pain (LBP). Stratified care strategies may be worthwhile, but rely on early and accurate patient screening using a valid and reliable instrument. The purpose of this study was to evaluate the performance of LBP screening instruments for determining risk of poor outcome in adults with LBP of less than 3 months duration.Medline, Embase, CINAHL, PsycINFO, PEDro, Web of Science, SciVerse SCOPUS, and Cochrane Central Register of Controlled Trials were searched from June 2014 to March 2016. Prospective cohort studies involving patients with acute and subacute LBP were included. Studies administered a prognostic screening instrument at inception and reported outcomes at least 12 weeks after screening. Two independent reviewers extracted relevant data using a standardised spreadsheet. We defined poor outcome for pain to be ≥ 3 on an 11-point numeric rating scale and poor outcome for disability to be scores of ≥ 30% disabled (on the study authors' chosen disability outcome measure).We identified 18 eligible studies investigating seven instruments. Five studies investigated the STarT Back Tool: performance for discriminating pain outcomes at follow-up was 'non-informative' (pooled AUC = 0.59 (0.55-0.63), n = 1153) and 'acceptable' for discriminating disability outcomes (pooled AUC = 0.74 (0.66-0.82), n = 821). Seven studies investigated the Orebro Musculoskeletal Pain Screening Questionnaire: performance was 'poor' for discriminating pain outcomes (pooled AUC = 0.69 (0.62-0.76), n = 360), 'acceptable' for disability outcomes (pooled AUC = 0.75 (0.69-0.82), n = 512), and 'excellent' for absenteeism outcomes (pooled AUC = 0.83 (0.75-0.90), n = 243). Two studies investigated the Vermont Disability Prediction Questionnaire and four further instruments were investigated in single studies only.LBP screening instruments administered in primary care perform poorly at assigning higher risk scores to individuals who develop chronic pain than to those who do not. Risks of a poor disability outcome and prolonged absenteeism are likely to be estimated with greater accuracy. It is important that clinicians who use screening tools to obtain prognostic information consider the potential for misclassification of patient risk and its consequences for care decisions based on screening. However, it needs to be acknowledged that the outcomes on which we evaluated these screening instruments in some cases had a different threshold, outcome, and time period than those they were designed to predict.PROSPERO international prospective register of systematic reviews registration number CRD42015015778 .

Background Delivering efficient and effective healthcare is crucial for a condition as burdensome as low back pain (LBP). Stratified care strategies may be worthwhile, but rely on early and accurate patient screening using a valid and reliable instrument. The purpose of this study was to evaluate the performance of LBP screening instruments for determining risk of poor outcome in adults with LBP of less than 3 months duration. Methods Medline, Embase, CINAHL, PsycINFO, PEDro, Web of Science, SciVerse SCOPUS, and Cochrane Central Register of Controlled Trials were searched from June 2014 to March 2016. Prospective cohort studies involving patients with acute and subacute LBP were included. Studies administered a prognostic screening instrument at inception and reported outcomes at least 12 weeks after screening. Two independent reviewers extracted relevant data using a standardised spreadsheet. We defined poor outcome for pain to be ≥ 3 on an 11-point numeric rating scale and poor outcome for disability to be scores of ≥ 30% disabled (on the study authors' chosen disability outcome measure). Results We identified 18 eligible studies investigating seven instruments. Five studies investigated the STarT Back Tool: performance for discriminating pain outcomes at follow-up was ‘non-informative’ (pooled AUC = 0.59 (0.55–0.63), n = 1153) and ‘acceptable’ for discriminating disability outcomes (pooled AUC = 0.74 (0.66–0.82), n = 821). Seven studies investigated the Orebro Musculoskeletal Pain Screening Questionnaire: performance was ‘poor’ for discriminating pain outcomes (pooled AUC = 0.69 (0.62–0.76), n = 360), ‘acceptable’ for disability outcomes (pooled AUC = 0.75 (0.69–0.82), n = 512), and ‘excellent’ for absenteeism outcomes (pooled AUC = 0.83 (0.75–0.90), n = 243). Two studies investigated the Vermont Disability Prediction Questionnaire and four further instruments were investigated in single studies only. Conclusions LBP screening instruments administered in primary care perform poorly at assigning higher risk scores to individuals who develop chronic pain than to those who do not. Risks of a poor disability outcome and prolonged absenteeism are likely to be estimated with greater accuracy. It is important that clinicians who use screening tools to obtain prognostic information consider the potential for misclassification of patient risk and its consequences for care decisions based on screening. However, it needs to be acknowledged that the outcomes on which we evaluated these screening instruments in some cases had a different threshold, outcome, and time period than those they were designed to predict. Systematic review registration PROSPERO international prospective register of systematic reviews registration number CRD42015015778. Electronic supplementary material The online version of this article (doi:10.1186/s12916-016-0774-4) contains supplementary material, which is available to authorized users.

Highlights • Patient education is recommended in the primary care management of acute low back pain. • The PREVENT Trial is the first placebo-controlled randomized trial to evaluate the efficacy of patient education. • Statistical analysis plans increase the transparency around how researchers plan to estimate and interpret treatment effects from randomized trials. • This protocol describes the pre-specified principles, methods, and procedures to be adhered to in the statistical analysis of the PREVENT trial data., Background Statistical analysis plans increase the transparency of decisions made in the analysis of clinical trial results. The purpose of this paper is to detail the planned analyses for the PREVENT trial, a randomized, placebo-controlled trial of patient education for acute low back pain. Results We report the pre-specified principles, methods, and procedures to be adhered to in the main analysis of the PREVENT trial data. The primary outcome analysis will be based on Mixed Models for Repeated Measures (MMRM), which can test treatment effects at specific time points, and the assumptions of this analysis are outlined. We also outline the treatment of secondary outcomes and planned sensitivity analyses. We provide decisions regarding the treatment of missing data, handling of descriptive and process measure data, and blinded review procedures. Conclusions Making public the pre-specified statistical analysis plan for the PREVENT trial minimizes the potential for bias in the analysis of trial data, and in the interpretation and reporting of trial results. Trial registration ACTRN12612001180808 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12612001180808)

Background: Low back pain (LBP) affects millions of people worldwide, and misconceptions about effective treatment options for this condition are very common. Websites sponsored by organizations recognized as trustworthy by the public, such as government agencies, hospitals, universities, professional associations, health care organizations and consumer organizations are an important source of health information for many people. However, the content of these websites regarding treatment recommendations for LBP has not been fully evaluated. Objective: This study aimed to determine the credibility, accuracy, and comprehensiveness of treatment recommendations for LBP in noncommercial, freely accessible websites. Methods: We conducted a systematic review of websites from government agencies, hospitals, universities, professional associations, health care organizations and consumer organizations. We conducted searches on Google. Treatment recommendations were coded based on the 2016 National Institute for Health and Care Excellence (NICE) guidelines and the 2017 American College of Physicians guideline on LBP. Primary outcomes were credibility of the website (4-item Journal of the American Medical Association benchmark), accuracy (proportion of website treatment recommendations that were appropriate), and comprehensiveness of website treatment recommendations (proportion of guideline treatment recommendations that were appropriately covered by a website). Results: We included 79 websites from 6 English-speaking countries. In terms of credibility, 31% (25/79) of the websites clearly disclosed that they had been updated after the publication of the NICE guidelines. Only 43.28% (487/1125) website treatment recommendations were judged as accurate. Comprehensiveness of treatment recommendations correctly covered by websites was very low across all types of LBP. For acute LBP, an average of 28% (4/14) guideline recommendations were correctly covered by websites. Websites for radicular LBP were the least comprehensive, correctly covering an average of 16% (2.3/14) recommendations. Conclusions: Noncommercial freely accessible websites demonstrated low credibility standards, provided mostly inaccurate information, and lacked comprehensiveness across all types of LBP.

Highlights • Reassurance is a frequently utilized yet poorly understood clinical skill. • Emotional distress is an important driver of healthcare use. • Diagnostic test results are not reassuring. • Some attempts at reassurance can increase rather than decrease concern. • Patient education is a promising way for clinicians to manage emotional distress., Introduction Reassurance is the removal of fears and concerns about illness. In practice reassurance for non-specific conditions, where a diagnosis is unclear or unavailable, is difficult and can have unexpected effects. Many clinical guidelines for non-specific conditions such as low back pain recommend reassurance. Until recently, there was little evidence on how to reassure patients effectively. Results High distress causes patients to consult more often for low back pain. To reduce distress, clinicians should provide structured education, which is effective in the short- and long-term. A newly developed online prognostic tool has the potential to improve the quality of reassurance and reduce the number of inappropriate interventions provided for low back pain. Conclusion Targeted reassurance, including enhanced, prognosis-specific education, could optimize reassurance and possibly prevent disabling symptoms.

Prognostic screening in patients with low back pain (LBP) offers a practical approach to guiding clinical decisions. Whether screening is helpful in secondary care is unclear. This prospective cohort study in adults with LBP placed on outpatient clinic waiting lists, compared the performance of the short-form Orebro Musculoskeletal Pain Screening Questionnaire, the Predicting the Inception of Chronic Pain Tool, and the STarT Back Tool. We assessed predictive validity for outcome at 4-month follow-up, by calculating estimates of discrimination, calibration, and overall performance. We applied a decision curve analysis approach to describe the clinical value of screening in this setting via comparison with a 'treat-all' strategy. Complete data were available for 89% of enrolled participants (n = 195). Eighty-four percent reported 'poor outcome' at follow-up. The area under the receiver operating characteristic curve (95% confidence interval) was .66 (.54-.78) for the Orebro Musculoskeletal Pain Screening Questionnaire, .61 (.49-.73) for the Predicting the Inception of Chronic Pain Tool, and .69 (.51-.80) for the STarT Back Tool. All instruments were miscalibrated and underestimated risk. The decision curve analysis indicated that, in this setting, prognostic screening does not add value over and above a treat-all approach. The potential for LBP patients to be misclassified using screening and the high incidence of nonrecovery indicate that care decisions should be made with the assumption that all patients are 'at risk.'. Perspective: This article presents a head-to-head comparison of 3 LBP screening instruments in a secondary care setting. Early patient screening is likely to hold little clinical value in this setting and care pathways that consider all patients at risk of a poor outcome are suggested to be most appropriate. Refereed/Peer-reviewed

IntroductionLittle is known about how to reduce unnecessary imaging for low back pain. Understanding clinician, patient and general public beliefs about imaging is critical to developing strategies to reduce overuse.ObjectiveTo synthesise qualitative research that has explored clinician, patient or general public beliefs about diagnostic imaging for low back pain.Methods and analysisWe will perform a qualitative evidence synthesis of relevant qualitative research exploring clinician, patient and general public beliefs about diagnostic imaging for low back pain. Exclusions will be studies not using qualitative methods and studies not published in English. Studies will be identified using sensitive search strategies in MEDLINE, EMBASE, CINAHL, AMED and PsycINFO. Two reviewers will independently apply inclusion and exclusion criteria, extract data, and use the Critical Appraisal Skills Programme quality assessment tool to assess the quality of included studies. To synthesise the data we will use a narrative synthesis approach that involves developing a theoretical model, conducting a preliminary synthesis, exploring relations in the data, and providing a structured summary. We will code the data using NVivo. At least two reviewers will independently apply the thematic framework to extracted data. Confidence in synthesis findings will be evaluated using the GRADE Confidence in the Evidence from Reviews of Qualitative Research tool.Ethics and disseminationEthical approval is not required to conduct this review. We will publish the results in a peer-reviewed journal.PROSPERO registration numberCRD42017076047.

Purpose: To determine whether emotional distress reported at the initial consultation affects subsequent healthcare use either directly or indirectly via moderating the influence of symptoms. Methods: Longitudinal observational study of 2891 participants consulting primary care for low back pain. Negative binomial regression models were constructed to estimate independent effects of emotional distress on healthcare use. Potential confounders were identified using directed acyclic graphs. Results: After the initial consultation, participants had a mean (SD) of one (1.2) visit for back pain over 3 months, and nine (14) visits for back pain over 12 months. Higher reports of anxiety during the initial consultation led to increased short-term healthcare use (IRR 1.06, 95 % CI 1.01–1.11) and higher reports of depression led to increased long-term healthcare use (IRR 1.04, 95 % CI 1.02–1.07). The effect sizes suggest that a patient with a high anxiety score (8/10) would consult 50 % more frequently over 3 months, and a person with a high depression score (8/10) would consult 30 % more frequently over 12 months, compared to a patient with equivalent pain and disability and no reported anxiety or depression. Conclusions: Emotional distress in the acute stage of low back pain increased subsequent consultation rates. Interventions that target emotional distress during the initial consultation are likely to reduce costly and potentially inappropriate future healthcare use for patients with non-specific low back pain. Refereed/Peer-reviewed

Introduction Around 40% of people presenting to primary care with an episode of acute low back pain develop chronic low back pain. In order to reduce the risk of developing chronic low back pain, effective secondary prevention strategies are needed. Early identification of at-risk patients allows clinicians to make informed decisions based on prognostic profile, and researchers to select appropriate participants for secondary prevention trials. The aim of this study is to develop and validate a prognostic screening tool that identifies patients with acute low back pain in primary care who are at risk of developing chronic low back pain. This paper describes the methods and analysis plan for the development and validation of the tool. Methods/analysis The prognostic screening tool will be developed using methods recommended by the Prognosis Research Strategy (PROGRESS) Group and reported using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) statement. In the development stage, we will use data from 1248 patients recruited for a prospective cohort study of acute low back pain in primary care. We will construct 3 logistic regression models to predict chronic low back pain according to 3 definitions: any pain, high pain and disability at 3 months. In the validation stage, we will use data from a separate sample of 1643 patients with acute low back pain to assess the performance of each prognostic model. We will produce validation plots showing Nagelkerke R2 and Brier score (overall performance), area under the curve statistic (discrimination) and the calibration slope and intercept (calibration). Ethics and dissemination Ethical approval from the University of Sydney Ethics Committee was obtained for both of the original studies that we plan to analyse using the methods outlined in this protocol (Henschke et al, ref 11-2002/3/3144; Williams et al, ref 11638).

Introduction Pain education is a complex intervention developed to help clinicians manage low back pain. Although complex interventions are usually evaluated by their effects on outcomes, such as pain or disability, most do not directly target these outcomes; instead, they target intermediate factors that are presumed to be associated with the outcomes. The mechanisms underlying treatment effects, or the effect of an intervention on an intermediate factor and its subsequent effect on outcome, are rarely investigated in clinical trials. This leaves a gap in the evidence for understanding how treatments exert their effects on outcomes. Mediation analysis provides a method for identifying and quantifying the mechanisms that underlie interventions. Aim To determine whether the effect of pain education on pain and disability is mediated by changes in self-efficacy, catastrophisation and back pain beliefs. Design Causal mediation analysis of the PREVENT randomised controlled trial. Participants and setting Two hundred and two participants with acute low back pain from primary care clinics in the Sydney metropolitan area. Intervention Participants will be randomised to receive either ‘pain education' (intervention group) or ‘sham education' (control group). Measurements All outcome measures (including patient characteristics), primary outcome measures (pain and disability), and putative mediating variables (self-efficacy, catastrophisation and back pain beliefs) will be measured prior to randomisation. Putative mediators and primary outcome measures will be measured 1 week after the intervention, and primary outcome measures will be measured 3 months after the onset of low back pain. Analysis Causal mediation analysis under the potential outcomes framework will be used to test single and multiple mediator models. A sensitivity analysis will be conducted to evaluate the robustness of the estimated mediation effects on the influence of violating sequential ignorability – a critical assumption for causal inference. Discussion and significance Mediation analysis of clinical trials can estimate how much the total effect of the treatment on the outcome is carried through an indirect path. Using mediation analysis to understand these mechanisms can generate evidence that can be used to tailor treatments and optimise treatment effects. In this study, the causal mediation effects of a pain education intervention for acute non-specific low back pain will be estimated. This knowledge is critical for further development and refinement of interventions for conditions such as low back pain.