Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol IMPLEmenting a clinical practice guideline for acute low back pain evidence-based manageMENT in general practice (IMPLEMENT): Cluster randomised controlled trial study protocol Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain Enhanced implementation of low back pain guidelines in general practice: study protocol of a cluster randomised controlled trial Cost-effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for nonspecific low back pain: design of a stepped-wedge cluster randomised controlled trial How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists A review and proposal for a core set of factors for prospective cohorts in low back pain: a consensus statement. Routine primary care management of acute low back pain: adherence to clinical guidelines Effect of Low Back Pain Risk-Stratification Strategy on Patient Outcomes and Care Processes: the MATCH Randomized Trial in Primary Care Effect of a multidisciplinary program for the prevention of low back pain in hospital employees: a randomized controlled trial. Implementing evidence-informed policy into practice for health care professionals managing people with low back pain in Australian rural settings: a preliminary prospective single-cohort study. Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: The UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761] The Effectiveness of a Posted Information Package on the Beliefs and Behavior of Musculoskeletal Practitioners: The UK Chiropractors, Osteopaths, and Musculoskeletal Physiotherapists Low Back Pain ManagemENT (COMPLeMENT) Randomized Trial The natural course of low back pain: a systematic critical literature review Can Primary Care for Back and/or Neck Pain in the Netherlands Benefit From Stratification for Risk Groups According to the STarT Back Tool Classification? Implementation of the Dutch Low Back Pain Guideline for General Practitioners: A Cluster Randomized Controlled Trial Adherence of Irish general practitioners to European guidelines for acute low back pain: a prospective pilot study.
Background Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care . A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines . Further , the review recommended the use of theory in the development of implementation interventions . A clinical practice guideline for the management of acute low-back pain has been developed in Australia ( 2003 ) . Acute low-back pain is a common condition , has a high burden , and there is some indication of an evidence - practice gap in the allied health setting . This provides an opportunity to develop and test a theory-based implementation intervention which , if effective , may provide benefits for patients with this condition . Aims This study aims to estimate the effectiveness of a theory-based intervention  to increase allied health practitioners ' ( physiotherapists and chiropractors in Victoria , Australia ) compliance with a clinical practice guideline for acute non-specific low back pain ( LBP ) , compared with providing practitioners with a printed copy of the guideline . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray  , and improving mean level of disability for patients three months post-onset of acute LBP . Methods The design of the study is a cluster r and omised trial . Restricted r and omisation was used to r and omise 210 practice s ( clusters ) to an intervention or control group . Practitioners in the control group received a printed copy of the guideline . Practitioners in the intervention group received a theory-based intervention developed to address prospect ively identified barriers to practitioner compliance with the guideline . The intervention primarily consisted of an educational symposium .  Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period , three months post the intervention symposia , are eligible for inclusion . Sample size calculations are based on recruiting between 15 to 40 patients per practice . Outcome assessors will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN12609001022257 ( date registered 25th November 2009 Background Evidence generated from reliable research is not frequently implemented into clinical practice . Evidence -based clinical practice guidelines are a potential vehicle to achieve this . A recent systematic review of implementation strategies of guideline dissemination concluded that there was a lack of evidence regarding effective strategies to promote the uptake of guidelines . Recommendations from this review , and other studies , have suggested the use of interventions that are theoretically based because these may be more effective than those that are not . An evidence -based clinical practice guideline for the management of acute low back pain was recently developed in Australia . This provides an opportunity to develop and test a theory-based implementation intervention for a condition which is common , has a high burden , and for which there is an evidence - practice gap in the primary care setting . Aim This study aims to test the effectiveness of a theory-based intervention for implementing a clinical practice guideline for acute low back pain in general practice in Victoria , Australia . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of patients who are referred for a plain x-ray  , and improving mean level of disability for patients three months post-consultation . Methods / Design This study protocol describes the details of a cluster r and omised controlled trial . Ninety-two general practice s ( clusters ) , which include at least one consenting general practitioner , will be r and omised to an intervention or control arm using restricted r and omisation . Patients aged 18 years or older who visit a participating practitioner for acute non-specific low back pain of less than three months duration will be eligible for inclusion . An average of twenty-five patients per general practice will be recruited , providing a total of 2,300 patient participants . General practitioners in the control arm will receive access to the guideline using the existing dissemination strategy . Practitioners in the intervention arm will be invited to participate in facilitated face-to-face workshops that have been underpinned by behavioural theory . Investigators ( not involved in the delivery of the intervention ) , patients , outcome assessors and the study statistician will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN012606000098538 ( date registered 14/03/2006 ) OBJECTIVE : The effect of clinical guidelines on re source utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied . We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain . DESIGN : Physician groups were r and omized to receive guideline education and individual feedback , supporting patient education material s , both , or neither . The impact on guideline adherence and re source utilization was evaluated during the 12-month period before and after implementation . PARTICIPANTS : Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practice s. INTERVENTIONS : Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders . The patient education component included written and videotaped material s on the care of low back pain . MAIN RESULTS : The clinician intervention was associated with an absolute increase in guideline -consistent behavior of 5.4 % in the intervention group versus a decline of 2.7 % in the control group ( P=.04 ) . The patient education intervention produced no significant change in guideline -consistent behavior , but was poorly adopted . Patient characteristics including duration of pain , prior history of low back pain , and number of visits during the illness episode were strong predictors of service utilization and guideline -consistent behavior . CONCLUSIONS : Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline -consistent behavior . Patient education material s did not enhance guideline effectiveness . Implementation barriers could limit the utility of this approach in usual care setting Background Evidence -based clinical practice guidelines may improve treatment quality , but the uptake of guideline recommendations is often incomplete and slow . Recently new low back pain guidelines are being launched in Denmark . The guidelines are considered to reduce personal and public costs . The aim of this study is to evaluate whether a complex , multifaceted implementation strategy of the low back pain guidelines will reduce secondary care referral and improve patient outcomes compared to the usual simple implementation strategy . Methods / design In a two-armed cluster r and omised trial , 100 general practice s ( clusters ) and 2,700 patients aged 18 to 65 years from the North Denmark region will be included . Practice s are r and omly allocated 1:1 to a simple or a complex implementation strategy . Intervention practice s will receive a complex implementation strategy , including guideline facilitator visits , stratification tools , and quality reports on low back pain treatment . Primary outcome is referral to secondary care . Secondary outcomes are pain , physical function , health-related quality of life , patient satisfaction with care and treatment outcome , employment status , and sick leave . Primary and secondary outcomes pertain to the patient level . Assessment s of outcomes are blinded and follow the intention-to-treat principle . Additionally , a process assessment will evaluate the degree to which the intervention elements will be delivered as planned , as well as measure changes in beliefs and behaviours among general practitioners and patients . Discussion This study provides knowledge concerning the process and effect of an intervention to implement low back pain guidelines in general practice , and will provide insight on essential elements to include in future implementation strategies in general practice .Trial registration Registered as NCT01699256 on Clinical Trials.gov Background Low back pain ( LBP ) is one of the most prevalent and expensive health care problems in industrialised countries . LBP leads to high health care utility and productivity losses ; leaving the individual , the employer , and society with substantial costs . To improve the care for LBP patients and reduce the high societal and financial burden of LBP , in 2010 the ‘ Multidisciplinary care guideline for nonspecific low back pain ’ was developed in the Netherl and s. The current paper describes the design of a study aim ing to evaluate the ( cost- ) effectiveness of a multifaceted strategy to implement this guideline . Methods In a cluster-r and omised controlled trial , the ( cost- ) effectiveness of a multifaceted implementation strategy will be compared to passive guideline dissemination . Using a stepped-wedge approach , participating general practitioners , physiotherapists , and occupational physicians are allocated into clusters and will attend a multidisciplinary continuing medical education training session . The timing these clusters receive the training is the unit of r and omisation . LBP patients visiting the participating health care providers are invited to participate in the trial and will receive access to a multimedia intervention aim ed at improving beliefs , cognitions , and self-management . The primary outcome measure of this study is patient back beliefs . Secondary outcome measures on patient level include pain , functional status , quality of life , health care utility , and productivity losses . Outcome measures on professional level include knowledge and attitude towards the guideline , and guideline adherence . A process evaluation for the implementation strategy will be performed among the health care providers and the patients . Furthermore , a qualitative subgroup analysis among patients with various ethnic background s will be performed . Discussion This study will give insight into the ( cost- ) effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for non-specific back pain to improve outcomes on patient and professional level . The valuable information gained with this study may prove useful for policy-makers , health care providers , and research ers who are in the process of reducing the burden of back pain on individuals and society . Trial Registration Netherl and s Trial Register ( NTR ) : NTR4329 . Registered December 20th , 2013 & NA ; Guidelines for the management of low back pain ( LBP ) have existed for many years , but adherence to these by health care practitioners ( HCPs ) remains suboptimal . The aim of this study was to measure the attitudes , beliefs and reported clinical behaviour of UK physiotherapists ( PTs ) and general practitioners ( GPs ) about LBP and to explore the associations between these . A cross‐sectional postal survey of GPs ( n = 2000 ) and PTs ( n = 2000 ) was conducted that included the  Pain Attitudes and Beliefs Scale ( PABT.PT )  , and a vignette of a  patient with non‐specific LBP ( NSLBP )  with questions asking about recommendations for work , activity and bedrest . Data from 1022 respondents ( 442 GPs and 580 PTs ) who had recently treated patients with LBP were analysed . Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations , 28 % reported they would advise this patient to remain off work . Work advice was significantly related to the PABS.PT scores with higher biomedical ( F1,986 = 77.5 , p < 0.0001 ) and lower behavioural ( F1,981 = 31.9 , p < 0.001 ) scores associated with advice to remain off work . We have demonstrated that the attitudes and reported practice behaviour of UK GPs and PTs for patients with NSLBP are diverse . Many HCPs held the belief that LBP necessitates some avoidance of activities and work . The attitudes and beliefs of these HCPs were associated with their self‐reported clinical behaviour regarding advice about work . Future studies need to investigate whether approaches aim ed at modifying these HCP factors can lead to improved patient outcomes Introduction The Multinational Musculoskeletal Inception Cohort Study ( MMICS ) Statement is a consensus statement aim ed at improving the quality of prospect i ve investigations into the transition from early stages of low back pain ( LBP ) to persistent problems . The statement aims to help improve the quality of such studies by recommending an agreed minimal list of measures for inclusion in baseline data collection . The MMICS Statement is primarily aim ed at research ers who want to investigate prognosis in LBP , and this will allow data from cohorts to be pooled and will facilitate comparisons between different health care systems . One approach to preventing acute new episodes of LBP ( up to 3 weeks from onset ) from developing into persistent disabling pain is to identify those individuals with LBP who are most likely to progress to chronic disability . Targeting interventions at those at highest risk could reduce the population burden of chronic LBP . A wide range of baseline parameters have been associated with poor outcome in inception cohort studies ( 1–6 ) . Few existing studies have been of sufficient size and method ologic rigor to produce conclusive findings . Even in method ologically robust studies , baseline factors only account for a small proportion of the variance in outcome ( 7 ) , typically around 30 % . Systematic review s of the literature could not pool data because studies used different measurements ( 1–3 ) . Despite some information on physical , psychosocial , and work-related risk factors , it has not been possible to adequately estimate the comparative impact of individual psychosocial and societal factors on the transition from acute to persistent disabling LBP . How to address this problem was one focus of the VI International Forum for Primary Care Research in Low Back Pain held in April 2003 . A steering group for the collaboration was appointed , and 8 national team leaders volunteered to recruit teams of national experts . Three additional team leaders were recruited by the steering group ( Australia , France , and Germany ) . Independent experts were invited to advise on the quality of the MMICS process . The MMICS steering group , located in the UK , met regularly and included expert research ers in clinical and outcome factors in back pain ( AB ) , work-related issues in back pain ( AKB ) , psychosocial aspects of back pain ( TP and RS ) , and general practice aspects of back pain ( MU ) . The MMICS Statement set out to include 1 ) a minimal but comprehensive number of predictor factors based on current evidence and theory ; 2 ) appropriate measurement instruments for agreed predictor factors based on their clinometric properties , availability , and practical characteristics ; and 3 ) a minimum set of followup measures , including recommendations about measurement and timing One of the major challenges for general practitioners is to manage individuals with acute low back pain appropriately to reduce the risk of chronicity . A prospect i ve study was design ed to assess the actual management of acute low back pain in one primary care setting and to determine whether existing practice patterns conform to published guidelines . Twenty-four family physicians from public primary care centers of the Basque Health Service in Bizkaia , Basque Country ( Spain ) , participated in the study . A total of 105 patients aged 18–65 years presenting with acute low back pain over a 6-month period were included . Immediately after consultation , a research assistant performed a structured clinical interview . The patients ’ care provided by the general practitioner was compared with the Agency for Health Care Policy and Research ( AHCPR ) guidelines and guidelines issued by the Royal College of General Practitioners . The diagnostic process showed a low rate of appropriate use of history ( 27 % ) , physical examination ( 32 % ) , lumbar radiographs ( 31 % ) , and referral to specialized care ( 33 % ) . Although the therapeutic process showed a relatively high rate of appropriateness in earlier mobilization ( 77 % ) and educational advice ( 65 % ) , only 23 % of patients were taught about the benign course of back pain . The study revealed that management of acute low back pain in the primary care setting is far from being in conformance with published clinical guidelines Background The STarT Back strategy for categorizing and treating patients with low back pain ( LBP ) improved patients ’ function while reducing costs in Engl and . Objective This trial evaluated the effect of implementing an adaptation of this approach in a US setting . Design The Matching Appropriate Treatments to Consumer Healthcare needs ( MATCH ) trial was a pragmatic cluster r and omized trial with a pre-intervention baseline period . Six primary care clinics were pair r and omized , three to training in the STarT Back strategy  and three to serve as  controls . Participants Adults receiving primary care for non-specific LBP were invited to provide data 2 weeks after their primary care visit and follow-up data 2 and 6 months ( primary endpoint ) later . Interventions The STarT Back risk-stratification strategy matches treatments for LBP to physical and psychosocial obstacles to recovery using patient-reported data ( the STarT Back Tool ) to categorize patients ’ risk of persistent disabling pain . Primary care clinicians in the intervention clinics attended six didactic sessions to improve their underst and ing LBP management and received in-person training in the use of the tool that had been incorporated into the electronic health record ( EHR ) . Physical therapists received 5 days of intensive training . Control clinics received no training . Main measures Primary outcomes were back-related physical function and pain severity . Intervention effects were estimated by comparing mean changes in patient outcomes after 2 and 6 months between intervention and control clinics . Differences in change scores by trial arm and time period were estimated using linear mixed effect models . Secondary outcomes included healthcare utilization . Key Results Although clinicians used the tool for about half of their patients , they did not change the treatments they recommended . The intervention had no significant effect on patient outcomes or healthcare use . Conclusions A re source -intensive intervention to support stratified care for LBP in a US healthcare setting had no effect on patient outcomes or healthcare use . Trial Registration National Clinical Trial Number NCT02286141 BACKGROUND Hospital workers with physically dem and ing jobs are at risk for developing recurrent LBP . There is a lack of studies evaluating multidisciplinary prevention of  low back pain ( LBP ) in hospital workers . OBJECTIVE This r and omized controlled trial evaluates the effect of a multidisciplinary prevention program , focusing on a client-centred approach , on hospital workers at risk for developing LBP . METHODS Caregiving hospital workers were allocated to an experimental ( 12-week lasting multidisciplinary prevention program ) or control group ( no intervention ) . They were evaluated prior to the intervention and after a 6 months follow-up period . Primary outcome measures included incidence of LBP , work absenteeism and general health . Secondary outcomes included daily physical activity , job satisfaction and coping strategies . RESULTS A significant improvement was seen for passive coping after 6 months follow-up , but no significant differences were observed between groups in primary or other secondary outcome measures ( p > 0.05 ) . CONCLUSIONS A multidisciplinary prevention program fitting into a bio-psychosocial context may not have been intensive enough to promote a change in daily habitudes , and had no effect on work absenteeism , incidence of LBP or general health . Further research should determine whether prevention of LBP is possible in caregiving personnel OBJECTIVE To provide access to professional development opportunities for health care professionals , especially in rural Australian regions , consistent with recommendations in the Australian National Pain Strategy and state government policy . DESIGN AND SETTING A preliminary prospect i ve , single-cohort study design , which aligned health policy with evidence -informed clinical practice , evaluated the implementation and effectiveness of an interprofessional , health care provider pain education program ( hPEP ) for management of nonspecific low back pain ( nsLBP ) in rural Western Australia . INTERVENTION The 6.5-hour hPEP intervention was delivered to 60 care providers ( caseload nsLBP 19.8 % ± 22.5 ) at four rural WA regions . OUTCOME MEASURES Outcomes were recorded at baseline and 2 months post-intervention regarding attitudes , beliefs ( modified Health Care Providers Pain and Impairment Relationship Scale [ HC-PAIRS ] ) , Back Pain Beliefs Question naire [ BBQ ] ) , and self-reported evidence -based clinical practice ( knowledge and skills regarding nsLBP , rated on a 5-point Likert scale with 1 = nil and 5 = excellent ) . RESULTS hPEP was feasible to implement . At 2 months post-hPEP , responders ' ( response rate 53 % ) improved evidence -based beliefs were indicated by HC-PAIRS scores : baseline mean ( SD ) [ 43.2 ( 9.3 ) ] ; mean difference ( 95 % CI ) [ -5.9 ( -8.6 to -3.1 ) ] ; and BBQ baseline [ 34.3 ( 6.8 ) ] ; mean difference [ 2.1 ( 0.5 to 3.6 ) ] . Positive shifts were observed for all measures of clinical knowledge and skills ( P < 0.001 ) and increased assistance with planning lifestyle changes ( P < 0.001 ) , advice on self-management ( P = 0.010 ) , and for decreased referrals for spinal imaging ( P = 0.03 ) . CONCLUSIONS This policy-into- practice educational program is feasible to implement in rural Western Australia ( WA ) . While preliminary data are encouraging , a further r and omized controlled trial is recommended Background Low back pain ( LBP ) is a common and costly problem . Initiatives design ed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence -based clinical guidelines . The three professional groups of chiropractic , osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines . Even so , many seem unaware that such guidelines exist . Furthermore , the behaviour of at least some of these practitioners differs from that recommended in these guidelines .Few r and omised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control . All these trials have used a cluster design and most have method ological flaws . None specifically focus upon practitioner behaviour towards LBP patients . Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results . Although numerous LBP guidelines have been developed worldwide , there is a paucity of data on whether their dissemination actually changes practitioner behaviour . Primarily because of its low unit cost , sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy . The effect size of such a strategy , at an individual practitioner level , is likely to be small . However , if large numbers of practitioners are targeted , this strategy might achieve meaningful changes at a population level . Methods The primary aim of this prospect i ve , pragmatic r and omised controlled trial is to test the short-term effectiveness ( six-months following intervention ) of a directly-posted information package on the reported clinical behaviour ( primary outcome ) , attitudes and beliefs of UK chiropractors , osteopaths and musculoskeletal physiotherapists . We sought to r and omly allocate a combined sample of 1,800 consenting practitioners to receive either the information package ( intervention arm ) or no information above that gained during normal practice ( control arm ) . We collected question naire data at baseline and six-months post-intervention . The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity , work and bed-rest , that fall within categories previously defined by an expert consensus exercise as either ' guideline -consistent ' and ' guideline -inconsistent ' Study Design . R and omized controlled trial . Objective . To investigate the effect of a printed information package on the low back pain (LBP)-related beliefs and reported behavior of musculoskeletal practitioners ( chiropractors , osteopaths , and musculoskeletal physiotherapists ) across the United Kingdom . Summary of Background Data . A substantial proportion of musculoskeletal practitioners in United Kingdom does not follow current LBP guideline recommendations . Methods . In total , 1758 practitioners were r and omly allocated to either of the 2 study arms . One arm was posted a printed information package containing guideline recommendations for the management of LBP ( n = 876 ) and the other received no intervention ( n = 882 ) . The primary outcome measure consisted of 3 “ quality indicators ” ( activity , work , and bed-rest ) relating to a vignette of a patient with LBP , in which responses were dichotomized into either “ guideline -inconsistent ” or “ guideline -consistent . ” The secondary outcome was the practitioners ' LBP-related beliefs , measured using the Health Care Providers Pain and Impairment Relationship Scale . Outcomes were measured at baseline and at 6 months . Results . Follow-up at 6 months was 89 % . The changes in reported behavior on the quality indicators were as follows : activity , odds ratio ( OR ) 1.29 ( 95 % confidence interval , 1.03–1.61 ) and number needed to be treated ( NNT ) , 19 ( 15–28 ) ; work , OR 1.35 ( 1.07–1.70 ) and NNT 19 ( 14–29 ) ; and bed-rest , OR 1.31 ( 0.97–1.76 ) and NNT 47 ( 33–103 ) . The composite NNT for a change from guideline -inconsistent to guideline -consistent behavior on at least 1 of the 3 quality indicators was 10 ( 9–14 ) . LBP-related beliefs were significantly improved in those who were sent the information package ( P = 0.002 ) , but only to a small degree ( mean difference , 0.884 scale points ; 95 % confidence interval , 0.319–1.448 ) . Conclusion . Printed educational material can shift LBP-related beliefs and reported behaviors of musculoskeletal practitioners , toward practice that is more in line with guideline recommendations Background Most patients in the secondary care sector consulting for low back pain ( LBP ) seem to have a more or less constant course of pain during the ensuing year . Fewer patients with LBP in the primary care sector report continual pain over a one-year period . However , not much is known about the long-term course of LBP in the general population . A systematic critical literature review was undertaken in order to study the natural course of LBP over time in the general population . Methods A search of articles was performed in Pubmed , Cinahl and Psychinfo using the search terms ‘ epidemiology ’ ; ‘ low back pain ’ or ‘ back pain ’ ; ‘ prospect i ve study ’ or ‘ longitudinal study ’ ; ‘ follow-up ’ , ‘ natural course ’ , ‘ course ’ or ‘ natural history ’ ; ‘ general population ’ or ‘ working population ’ . Inclusion criteria were that one of the objectives was to study the course of (L)BP in the adult population , that the period of follow-up was at least 3 months , and that there were three points of observation or more . The review was undertaken by two independent review ers using three checklists relating to description of studies , quality and outcomes . The course of LBP was established in relation to those who , at baseline , were reported not to have LBP or to have LBP . Would this course be stable , fluctuating , worsening , or improving over time ? A synthesis of results in relation to common patterns was presented in a table and interpreted in a narrative form . Results Eight articles were included . Articles were different on time span , the number of surveys , and the definition of LBP . In six of the seven relevant studies , for those with no LBP at baseline , relatively substantial stable subgroups of people who continued to be LBP free were identified . In six of the seven relevant studies , definite stable subgroups of continued LBP were noted and improvement ( becoming pain free ) was never reported to be a common finding . Conclusion The status of LBP in individuals of the general population appears to be relatively stable over time , perhaps particularly so for those without LBP at baseline OBJECTIVE To evaluate whether current Dutch primary care clinicians offer tailored treatment to patients with low back pain ( LBP ) or neck pain ( NP ) according to their risk stratification , based on the Keele STarT ( Subgroup Targeted Treatment ) Back-Screening Tool ( SBT ) . DESIGN Prospect i ve cohort study with 3-month follow-up . SETTING Primary care . PARTICIPANTS General practitioners ( GPs ) and physiotherapists included patients ( N=284 ) with nonspecific LBP , NP , or both . INTERVENTIONS Patients completed a baseline question naire , including the Dutch SBT , for either LBP or NP . A follow-up measurement was conducted after 3 months to determine recovery ( using Global Perceived Effect Scale ) , pain ( using Numeric Pain Rating Scale ) , and function ( using Rol and Disability Question naire or Neck Disability Index ) . A question naire was sent to the GPs and physiotherapists to evaluate the provided treatment . MAIN OUTCOME MEASURES Prevalence of patients ' risk profile and clinicians ' applied care , and the percentage of patients with persisting disability at follow-up . A distinction was made between patients receiving the recommended treatment and those receiving the nonrecommended treatment . RESULTS In total , 12 GPs and 33 physiotherapists included patients . After 3 months , we analyzed 184 patients with LBP and 100 patients with NP . In the LBP group , 52.2 % of the patients were at low risk for persisting disability , 38.0 % were at medium risk , and 9.8 % were at high risk . Overall , 24.5 % of the patients with LBP received a low-risk treatment approach , 73.5 % a medium-risk , and 2.0 % a high-risk treatment approach . The specific agreement between the risk profile and the received treatment for patients with LBP was poor for the low-risk and high-risk patients ( 21.1 % and 10.0 % , respectively ) , and fair for medium-risk patients ( 51.4 % ) . In the NP group , 58.0 % of the patients were at low risk for persisting disability , 37.0 % were at medium risk , and 5.0 % were at high risk . Only 6.1 % of the patients with NP received the low-risk treatment approach . The medium-risk treatment approach was offered the most ( 90.8 % ) , and the high-risk approach was applied in only 3.1 % of the patients . The specific agreement between the risk profile and received treatment for patients with NP was poor for low-risk and medium-risk patients ( 6.3 % and 48.0 % , respectively ) ; agreement for high-risk patients could not be calculated . CONCLUSIONS Current Dutch primary care for patients with nonspecific LBP , NP , or both does not correspond to the recommended stratified-care approach based on the SBT , as most patients receive medium-risk treatment . Most low-risk patients are overtreated , and most high-risk patients are undertreated . Although the stratified-care approach has not yet been vali date d in Dutch primary care , these results indicate there may be substantial room for improvement Study Design . Cluster r and omized controlled trial for a multifaceted implementation strategy . Objectives . To assess the effectiveness of tailored  interventions ( multifaceted implementation strategy ) to implement the  Dutch low back pain guideline for general practitioners with regard to adherence to guideline recommendations . Summary of Background Data . Guidelines for the management of low back pain in primary care have been developed in various countries , but little is known about the optimal implementation strategy . A multifaceted implementation strategy was developed to overcome identified barriers to the implementation of the Dutch low back pain guideline for general practitioners . Methods . General practitioners were r and omized to an intervention or a control group . The general practitioners in the intervention group ( n = 21 ) received tailored interventions consisting of the Dutch low back pain guideline for general practitioners , a 2-hour educational and clinical practice workshop ; two scientific articles on low back pain management ; the guideline for occupational physicians ; a tool for patient education ; and a tool for reaching agreement on low back care with physical , exercise , and manual therapists . The control group ( n = 20 ) received no intervention . The participating general practitioners were asked to recruit consecutive patients with a new episode of low back pain as the main reason for consultation . General practitioners completed registration forms of each individual consultation with regard to the main outcome measures : advice and information , referral to other health-care providers , and prescription of medication . Results . Forty-one of the 67 r and omized general practitioners reported on a total of 616 consultations for 531 patients with nonspecific low back pain . The advice and explanation provided by the general practitioners , the prescription of paracetamol or nonsteroidal anti-inflammatory drugs , and prescription of pain medication on atime contingent or a pain contingent basis showed no statistically significant differences between the intervention and control groups . There were also no differences in overall referral rate . However , in follow-up consultations fewer patients were referred to a physical or exercise therapist by the general practitioners in the intervention group than in the control group . Conclusions . The multifaceted intervention strategy modestly improved implementation ( for parts of the recommendations in ) the Dutch low back pain guideline by general practitioners and produced small concomitant changes in patient management . The implementation strategy produced fewer referrals to therapists during follow-up consultations There are no national low back pain ( LBP ) clinical guidelines in Irel and , and neither the level of adherence of General Practitioners ( GPs ) to the European guidelines , nor the cost of LBP to the patient and the state , have been investigated . A prospect i ve pilot study was conducted on 54 consenting patients ( 18 M , 36F : mean age ( SD ) : 40.5 ( 14.3 ) years ) with a new episode of acute LBP ( <3 months ) attending one of nine participating GPs . Baseline demographic , LBP classification [ i.e. simple back ache ( SBA ) , nerve root pain ( NRP ) , serious spinal pathology ( SSP ) ] and primary care management data were recorded over a three month period . Adherence and costs were estimated based on : medication prescription , referral for investigations , treatment or consultations , and wage replacement costs ( time signed off work ) . For both SBA and NRP , medication prescriptions were consistent with European guideline recommendations , but not for referral for further treatment ( 39 % of SBA patients were referred on first visit ) , secondary care ( 54 % of NRP patients were referred on first visit ) , or discontinuation of work ( 50 % NRP patients on first GP visit ) . The average total cost ( direct and wage replacement ) for a single episode of LBP over 12 weeks was 20,531 Euros ( 20,300 - 20,762 ) . Direct costs accounted for 43 % [ 8874.36 Euros , ( 8643.37 - 9105.37 Euros ) ] and wage replacement costs 57 % ( 11,657 Euros ) . In conclusion , management of acute LBP in a cohort of GPs in Irel and was not consistent with European clinical guideline recommendations , and warrants higher levels of postgraduate education among GPs , as well as restructuring of primary care services , which should improve patient outcome and reduce costs
Clinicians believed that guidelines were categorical , prescriptive , and constrained professional practice ; however , popular clinical practice s superseded the guidelines .
Imaging referrals were used to manage consultations and to obtain definitive diagnoses .
Clinicians ' perceptions reflected a lack of content knowledge and underst and ing of how guidelines are developed .
DISCUSSION Addressing misconceptions and other barriers to uptake of evidence -based guidelines for managing LBP is needed to improve knowledge transfer and close the evidence - practice gap in the treatment of this common condition
INTRODUCTION Despite the availability of evidence -based guidelines for the management of low back pain ( LBP ) that contain consistent messages , large evidence - practice gaps in primary care remain .
OBJECTIVES To perform a systematic review and meta synthesis of qualitative studies that have explored primary care clinicians ' perceptions and beliefs about guidelines for LBP , including perceived enablers and barriers to guideline adherence .