Management of acute non-specific low back pain in the emergency department: do emergency physicians follow the guidelines? Results of a cross-sectional survey

Abstract

ObjectivesClinical guidelines for acute non-specific low back pain (LBP) recommend avoiding imaging studies or invasive treatments and to advise patients to stay active. The aim of this study was to evaluate the management of acute non-specific LBP in the emergency departments (ED).SettingWe invited all department chiefs of Swiss EDs and their physician staff to participate in a web-based survey using two clinical case vignettes of patients with acute non-specific LBP presenting to an ED. In both cases, no neurological deficits or red flags were present. Guideline adherence and low-value care was defined based on current guideline recommendations.ResultsIn total, 263 ED physicians completed at least one vignette, while 212 completed both vignettes (43% residents, 32% senior/attending physicians and 24% chief physicians). MRI was considered in 31% in vignette 1 and 65% in vignette 2. For pain management, non-steroidal anti-inflammatory drugs, paracetamol and metamizole were mostly used. A substantial proportion of ED physicians considered treatments with questionable benefit and/or increased risk for adverse events such as oral steroids (vignette 1, 12% and vignette 2, 19%), muscle relaxants (33% and 38%), long-acting strong opioids (25% and 33%) and spinal injections (22% and 43%). Although guidelines recommend staying active, 72% and 67% of ED physicians recommended activity restrictions.ConclusionManagement of acute non-specific LBP in the ED was not in agreement with current guideline recommendations in a substantial proportion of ED physicians. Overuse of imaging studies, the use of long-acting opioids and muscle relaxants, as well as recommendations for activity and work restrictions were prevalent and may potentially be harmful.

On-Site Physiotherapy in Emergency Department Patients Presenting with Nonspecific Low Back Pain: A Randomized Controlled Trial

“…The median ODI at day 7 in the control group was 13 (IQR, 5-19), whereas it was 11 (IQR, [6][7][8][9][10][11][12][13][14][15][16][17][18] in the intervention group (as demonstrated in Figure 3 and Table 2). The Wilcoxon test showed that the difference between the two groups was not significant (p = 0.854, effect size r = 0.0198 [95% CI 0.003 to 0.25]).…”

“…As there are no specific guidelines for the management of nonspecific LBP in EDs, a wide variation in the management of these patients has been described [ 5 , 6 ]. However, guidelines originating in primary care could be applied to the ED setting [ 5 ].…”

Fidelity to the acupuncture intervention protocol in the ACUpuncture In The EmergencY department for pain management (ACUITY) trial: Expanding the gold standard of STRICTA and CONSORT guidelines

“…While guidelines are slow to impact clinical practice in medicine, 22 , 23 ongoing research as well as dissemination of research evidence is crucial. Research into acupuncture effectiveness has moved from efficacy trials of very specific patient sets, using rote acupuncture prescriptions and non-inert sham acupuncture as a comparator 24 , 25 , 26 to more pragmatic trials: comparing acupuncture therapy to another therapy or usual care in a real-world settings with diverse real-world patients.…”