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Patients’ perceived needs for medical services for non-specific low back pain: A systematic scoping review

  • Louisa Chou,

    Roles Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

    Affiliation Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

  • Tom A. Ranger,

    Roles Data curation, Writing – original draft, Writing – review & editing

    Affiliation Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

  • Waruna Peiris,

    Roles Data curation, Writing – original draft, Writing – review & editing

    Affiliation Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

  • Flavia M. Cicuttini,

    Roles Conceptualization, Data curation, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Writing – review & editing

    Affiliation Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

  • Donna M. Urquhart,

    Roles Data curation, Investigation, Supervision, Writing – review & editing

    Affiliation Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

  • Kaye Sullivan,

    Roles Data curation, Methodology, Writing – review & editing

    Affiliation Monash University Library, Monash University, Melbourne, Victoria, Australia

  • Maheeka Seneviwickrama,

    Roles Conceptualization, Investigation, Methodology, Writing – review & editing

    Affiliation Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

  • Andrew M. Briggs,

    Roles Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

    Affiliations School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia, MOVE: muscle, bone & joint health, Victoria, Australia

  • Anita E. Wluka

    Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

    anita.wluka@monash.edu

    Affiliation Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

Patients’ perceived needs for medical services for non-specific low back pain: A systematic scoping review

  • Louisa Chou, 
  • Tom A. Ranger, 
  • Waruna Peiris, 
  • Flavia M. Cicuttini, 
  • Donna M. Urquhart, 
  • Kaye Sullivan, 
  • Maheeka Seneviwickrama, 
  • Andrew M. Briggs, 
  • Anita E. Wluka
PLOS
x

Abstract

Background

An improved understanding of patients’ perceived needs for medical services for low back pain (LBP) will enable healthcare providers to better align service provision with patient expectations, thus improving patient and health care system outcomes. Thus, we aimed to identify the existing literature regarding patients’ perceived needs for medical services for LBP.

Methods

A systematic scoping review was performed of publications identified from MEDLINE, EMBASE, CINAHL and PsycINFO (1990–2016). Descriptive data regarding each study, its design and methodology were extracted and risk of bias assessed. Aggregates of patients’ perceived needs for medical services for LBP were categorised.

Results

50 studies (35 qualitative, 14 quantitative and 1 mixed-methods study) from 1829 were relevant. Four areas of perceived need emerged: (1) Patients with LBP sought healthcare from medical practitioners to obtain a diagnosis, receive management options, sickness certification and legitimation for their LBP. However, there was dissatisfaction with the cursory and superficial approach of care. (2) Patients had concerns about pharmacotherapy, with few studies reporting on patients’ preferences for medications. (3) Of the few studies which examined the patients’ perceived need of invasive therapies, these found that patients avoided injections and surgeries (4) Patients desired spinal imaging for diagnostic purposes and legitimation of symptoms.

Conclusions

Across many different patient populations with data obtained from a variety of study designs, common themes emerged which highlighted areas of patient dissatisfaction with the medical management of LBP, in particular, the superficial approach to care perceived by patients and concerns regarding pharmacotherapy. Patients perceive unmet needs from medical services, including the need to obtain a diagnosis, the desire for pain control and the preference for spinal imaging. These issues need to be considered in developing approaches for the management of LBP in order to improve patient outcomes.

Introduction

Low back pain (LBP) is the leading cause of disability worldwide[1]. It is highly prevalent and is associated with pain, functional impairment, long-term incapacity, work absenteeism and high utilisation of healthcare[1,2]. LBP is costly, amounting to an estimated $88billion in the United States in 2013, with medical services comprising a considerable proportion of the incurred expenditure[3]. Consequently, several guidelines have been developed to guide the different presentations of acute and chronic back pain management, to direct clinical practice and to rationalise health care resource utilisation appropriately[410]. These guidelines recommend, as relevant to pain duration, a thorough clinical evaluation to exclude serious spinal pathology, judicious use of radiology, patient education to support optimal self-management, exercise therapy, psychological therapies for some people, short-term use of prescription medications and spinal manipulation for pain relief[610]. However, the publication and dissemination of guidelines does not ensure their implementation[11,12] and previous studies have demonstrated poor uptake of guidelines for the management of LBP [1317]. Instead, there has been a significant rise in opioid prescribing for LBP, with a resultant 660% increase in expenditure in the United States[18] and an increase in complications such as opioid dependence, addiction and mortality associated with overdose[19]. Spinal imaging has also been inappropriately utilised (overuse when not indicated and underuse when indicated) [20], which has further contributed to the growing financial burden of LBP, as well as other ramifications including additional investigations, referrals and potentially invasive procedures, that for most represent low-value care[8]. Furthermore, despite the recommendations for active rehabilitation such as exercise therapy for LBP, less than 50% of patients report being referred for active rehabilitation programs [17,21]. Collectively, these practices have contributed to unhelpful beliefs held by clinicians and the public concerning appropriate management of LBP, with calls for reframing how back pain is understood and managed [22].

Clinical practice guidelines face multiple impediments to implementation. Barriers to execution include environmental factors, such as resource allocation and costs, as well as clinician-related barriers, including a lack of agreement with clinical practice guidelines, lack of awareness and familiarity with recommendations[16,23]. Patient factors are also critical to the successful uptake and adherence to guidelines[16,17]. Clinicians have reported that patients’ preferences are an important cause of non-adherence to guidelines[17]. Patients’ non-adherence may be related to the high level of patient dissatisfaction with LBP management from medical practitioners[24,25], which has historically focused on a biomedical model of care. This biomedical approach is typically based on the scientific academic literature conducted by healthcare professionals. However this approach may be flawed as it neither adequately takes into account the patient perspective, nor satisfactorily consider the psychological and social drivers to the pain experience[26]. Although there are previous reviews summarising the evidence regarding patient expectations and experiences of healthcare for LBP, none of these have focussed on the patients’ perceived needs for medical services[26,27]. Therefore, we aimed to review the existing literature regarding patients’ perceived needs for medical services for LBP.

Methods

A systematic scoping review, based on the framework proposed by Arksey and O’Malley, was performed to enable a comprehensive exploration of the patients’ perspective[28]. Systematic scoping reviews are aimed at mapping key concepts, identifying gaps in the evidence, and reviewing different types of evidence[29,30]. This review was conducted within a larger project examining the patients’ perceived needs relating to musculoskeletal health[31]. The study methodology is similar to a previously published review examining patients’ perceived needs of health services for osteoarthritis[32].

Search strategy and study selection

The literature search was performed by electronically searching relevant databases (MEDLINE, EMBASE, CINAHL and PsycINFO) between January 1990 and June 2016. This time period was chosen to include relevant studies examining the current patient perspective. The search strategy (see S1 File for full OVID Medline search strategy) was developed by one of the study investigators (MS), with input from clinician researchers (Rheumatologists, FC and AW and Physiotherapist, AB), a patient representative and an academic librarian (KL). The strategy combined both MeSH terms and text words to capture information regarding patients’ perceived needs for medical services for LBP (S3 Supplementary Appendix). We have used the term “medical services” to include any service provided by medical practitioners, including general practitioners, specialist physicians and surgeons. A broad definition was used for “patient perceived needs”, which referred to patients’ perception of services that provided them with the capacity to benefit, including their expectations of satisfaction and preferences for medical services[33]. LBP was defined as non-specific LBP, with or without leg pain, excluding back pain from fractures, malignancy, infection and inflammatory spinal disorders.

Two reviewers, including LC and one of LC, TR and WP independently assessed the titles and abstracts of all studies identified by the initial search for relevance. Discrepancies in the inclusion of studies were reviewed by a third investigator (AW) to reach consensus. The initial screening was set to be open-ended to retain as many relevant studies as possible, with no restriction on the study methods. Studies were included if they met the following criteria: (1) included patients older than 18 years, (2) recruited patients with non-specific LBP and (3) reported on patients’ perceived needs for medical services for LBP. Studies were limited to human studies in the English language and full-text articles. No restrictions were applied to the prevalence of LBP and studies concerning acute, subacute and chronic LBP were included. Those that appeared to meet inclusion criteria were retrieved and the full text was assessed for relevance (LC). The reference lists of identified studies and review articles were searched to find possible further studies for inclusion.

Data extraction and analysis

The following data were systematically extracted by one investigator (LC) using a data extraction form specifically developed for this review: (1) primary study aim, (2) study population (patient age and gender, population source, population size and definition of LBP), (3) description of the study methods and (4) year of publication. Included studies were reviewed to identify aspects of medical services that patients had a preference for, expected, or were satisfied with using principles of meta-ethnography to synthesise qualitative data[34]. One author (LC) developed a framework of concepts and underlying themes, based on primary data in the included studies. Reciprocal translational analysis[34] was then undertaken to identify key concepts from individual studies and then translating and comparing these concepts to other studies to gradually explore and map the overarching themes. Data was extracted based on a customised data collection form. The framework of concepts and underlying themes were independently reviewed by three senior authors (FC and AW with over 15 years of clinical rheumatology consultant-level experience and a senior physiotherapist, AMB) to ensure accuracy of the extracted data and clinical meaningfulness.

Methodological quality assessment

To assess the methodological quality of the included studies, two from a panel of three (LC, TR, WP) independently assessed the methodological quality of all included studies.

Qualitative studies were assessed using the Critical Appraisal Skills Programme (CASP) tool[35]. The CASP is commonly used to assess qualitative research studies[35]. This tool has 10 questions that assists readers appraise articles based on appropriate research design (CASP questions 2–3), sampling (CASP question 4), data collection (CASP question 5), bias (CASP question 6), ethical issues (CASP question 7), data analysis (CASP question 8), research findings (CASP question 9) and the value of the research (CASP question 10). Each question is scored ‘yes’, ‘no’ or ‘cannot tell’ regarding the study quality and potential for bias. This is no overall score for the level of bias.

Hoy’s risk of bias tool was utilised to assess the external and internal validity of quantitative studies. This tool was developed to examine study quality and risk of bias in prevalence studies. This tool is comprised of 10 questions that assess the external validity (questions 1–4) and internal validity (questions 5–10) of a study. Each question is scored either ‘yes’ (low risk of bias) or ‘no’ (high risk of bias). Thus for a study to be determined to be at a low risk of bias it was defined as scoring 8 or more “yes” answers, moderate risk of bias was defined as 6 to 7 “yes” answers and high risk of bias was defined as 5 or fewer “yes” answers[36]. Disagreements were resolved initially through consensus, with remaining conflicts reviewed by the senior author (AW).

Results

Overview of articles

The search returned 1829 articles, of which 50 studies explored LBP patients’ perceived needs for medical services (Table 1). A PRISMA flow diagram detailing the study selection is shown in Fig 1. The descriptive characteristics of the included studies are shown in Table 1. Of these, 19 were from the United Kingdom[24,25,3754], 13 from the United States of America[5566], 9 from Europe[6775], 8 from Australasia[7683] and one from the Middle-East[84].

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Table 1. Studies identified in the systematic review of patients’ perceived needs for medical services for low back pain.

https://doi.org/10.1371/journal.pone.0204885.t001

The duration of back pain was either undefined or mixed in 39 (78%) studies[24,25,3743,4547,50,51,5565,6769,7277,7981,83,84] . While 11 (22%) studies reported on chronic back pain (>12 weeks duration)[44,48,49,5254,66,70,71,78,82].there were no studies on acute back pain alone (<6 weeks duration).

There were 35 qualitative studies[25,37,38,4046,4854,5961,6569,71,74,75,7779,8184] with participant numbers ranging from 7 to 110, with a median of 23. There were 14 quantitative studies[24,39,47,5558,6264,70,72,73,76,80], with a median participant number of 628 (range 124–1555). Mixed methods were utilised in 1 study[70], which had 348 participants. A total of 10976 participants were included in this review. Of the 32 studies that presented summary statistics, the median age of the participants was 50 years with a female predominance (58% female).

Quality of studies

Quality assessments of the included studies are presented in the Figs 2 and 3. The overall quality of qualitative studies was poor (Fig 2), especially for CASP criteria 4 to 6, indicating potential biases with data sampling and collection. The quantitative studies were of low quality: 10 studies were at high risk of bias, 4 studies were at moderate risk of bias and only 2 studies were at low risk of bias (Fig 3). The quality scores for both qualitative and quantitative studies largely reflected potential biases with recruitment strategy and data collection.

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Fig 2. CASP tool for qualitative studies.

1CASP 1: Was there a clear statement of the aims of the research 2CASP 2: Is a qualitative methodology appropriate? 3CASP 3:Was the research design appropriate to address the aims of the research? 4CASP 4: Was the recruitment strategy appropriate to the aims of the research? 5CASP 5: Was the data collected in a way that addressed the research issue? 6CASP 6: Has the relationship between researcher and participants been adequately considered? 7CASP 7: Have ethical issues been taken into consideration? 8CASP 8: Was the data analysis sufficiently rigorous? 9CASP 9: Is there a clear statement of findings? 10CASP 10: How valuable is the research?

https://doi.org/10.1371/journal.pone.0204885.g002

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Fig 3. Hoy et al’s Risk of Bias tool for quantitative studies.

1Criteria 1:Was the study’s target population a close representation of the national population in relation to relevant variables? 2Criteria 2: Was the sampling frame a true or close representation of the target population? 3Criteria 3: Was some form of random selection used to select the sample OR was a census taken? 4Criteria 4: Was the likelihood of nonresponse bias minimal? 5Criteria 5: Were data collected directly from the subjects? 6Criteria 6: Was an acceptable case definition used in the study? 7Criteria 7: Was the study instrument that measured the parameter of interest shown to have validity and reliability? 8Criteria 8: Was the same mode of data collection used for all subjects? 9Criteria 9: Was the length of the shortest prevalence period for the parameter of interest appropriate? 10Criteria 10: Were the numerator(s) and denominator(s) for the parameter of interest appropriate.

https://doi.org/10.1371/journal.pone.0204885.g003

Results of review

Four areas of perceived need were identified from the included studies (Tables 25).

The perceived need for medical practitioners (Table 2)

Twenty-three papers discussed the patients’ perceived role of the medical practitioner in the management of LBP[25,37,38,40,43,50,52,53,59,61,67,69,73,74,7985]. A consistent theme that emerged from patients recruited from general practice [69,81,84,86], the community[43,60] and tertiary care was the need to obtain a diagnosis and a cause of the pain[37,38,59,60,67,69,79,81,84]. Other reasons for seeking medical care included a need to obtain medications for pain relief[50,51,61,80], to receive advice and discussion of options for LBP management[38,61,85], to receive sickness certification and legitimation of their back pain[25,51,52]. Patients also considered consultation with primary care medical practitioners as an opportunity to explore alternative medicines[25,61] and to obtain referrals to specialist medical or surgical services[73]. Patients generally viewed medical practitioners to be knowledgeable about their pain[53,79] and could provide individual assessment [83]. Westmoreland found that patients perceived the strengths of the medical practitioner to include continuity of care, listening and counselling skills[40].

Six studies identified factors related to patient preferences regarding the role of medical practitioners in LBP and their satisfaction with them[24,41,49,62,63,74]. Patients described having faith in medical practitioners and a dependence on them and professions allied to medicine[49]. Fifty-one percent of patients thought that specialist referral was valuable[24]. Patients have reported reluctance by the general practitioner to refer patients to a specialist[41]. A single study by Carey found that patients who saw orthopaedic surgeons reported higher satisfaction than those who saw primary health care providers[63].

Patients expressed their reasons for consultation with a medical practitioner in 3 studies[58,59,64]. It has been reported that 98% of patients sought medical care due to difficulty with normal activity and 95% of patients wanted to find the cause of their pain[59]. Patients with greater pain and more severe functional impairment were more likely to seek medical help for their symptoms[58,64].

Eleven studies reported on the patients’ perceived inadequacies of the medical practitioners[37,40,41,4547,51,53,60,68,84]. Dissatisfaction with medical practitioners was reported from both qualitative[40,45,46,51,53,60,68,84,87,88] and quantitative[47] studies, as well as from all levels of care, including general practice[40,46,51,84,87], community-based[47,60], allied health clinics[45,47] and tertiary centres}[53,88]. Coole and Liddle found that patients felt there was little to be gained by consulting their primary care medical practitioner about their LBP[51,68] as they believed that they lacked specialist knowledge[41,46,47]. Patients felt that their consulting time with their medical practitioner was restricted and that therapeutic options were limited[40,45] and not individually tailored[47]. Furthermore, patients complained that medical practitioners had a cursory and superficial approach to the management of LBP, lacked empathy and had a tendency to be dismissive or delegitimise their symptoms[37,40,45,53,84]. Patients were disappointed that their medical practitioner did not provide a diagnosis[46,60] and they felt that the medical practitioner’s primary focus was on prescribing pain medications[53,68]. Also, patients were displeased with the delays in obtaining referrals to physiotherapy[45]. Patients also felt that once certain pathological causes of LBP were eliminated, medical practitioners appeared to slacken their investigations into the aetiology of pain[84].

The perceived need for pharmacological management (Table 3)

Thirteen studies examined the need for medications[24,39,41,43,48,51,57,65,67,69,74,81,82]. Of these, 5 studies reported that patients preferred medications[24,43,57,74,81], and that analgesics enabled them to cope with their social life and activities of daily living[67]. Patients believed that medications would enable relaxation of muscles, reduce inflammation, provide pain relief, enable activity and prevent worsening of LBP[48]. Narcotic use was reported in 1 study to be associated with patient satisfaction[57]. However, Buchbinder found that only 20% of patients presenting to an academic Emergency Department with LBP requested analgesics, and those that did utilised strategies of mitigation, indirection and deference which suggested that they were aware of the intricacies of their requests[65]. Other studies of patients attending either rehabilitation or pain management programs found that the patients were generally dismissive of medication as a treatment[50] and felt that drugs were neither important nor appropriate in the management of LBP[39]. Furthermore, patients have described their general practitioners as being too “keen to dish out drugs” and patients viewed medication use as treating symptoms rather than managing the actual problem[41]. Some patients would only take medications if strictly necessary[69] and were generally resistant to taking medication regularly[82].

Patients recruited from all levels of healthcare (i.e. general practice, the community, specialist referral centres and allied health practitioners) have concerns regarding medications, which were reported in 8 studies[42,44,48,54,65,74]. Patients were apprehensive about the side-effects of medications and the potential for addiction and desensitisation[4244,48]. Many patients felt trapped in a vicious cycle of increasing pain and consumption of drugs[42,74]. They were also concerned about the impact of medications on their work[51]. Furthermore, patients have reported confusion about medications and a lack of explanation by their healthcare provider[54]. Patients also expressed a reluctance to request analgesics for fear of stigmatisation, and if they did request medications, they were more likely to do so indirectly, particularly opioid-based analgesics[65].

The perceived need for interventional therapies (Table 4)

Five studies explored patients’ preferences for interventional treatment for LBP[44,48,55,70,75]. A single study by Lyons assessed patients’ preferences for injection therapy and found that most patients avoided injections and would “rather live with the pain”[44]. Two studies reported that patients would rather avoid surgery and viewed surgical intervention as a last resort[44,48]. Franz found that half of the patients referred to a neurosurgical clinic were willing to undergo surgery in the absence of pain if they had radiological abnormalities, however, only 33% of patients believed surgery to be more effective than physical therapy[55]. Patients were willing to wait 2 years for the effects of conservative treatment to avoid surgery[70]. In comparison, Lacroix stated that patients felt that “there comes a moment when an operation becomes inevitable”[75]. Patients who preferred surgical intervention were more likely to be male, have higher pain scores and a longer duration of pain[55,70].

The perceived need for imaging (Table 5)

Both qualitative and quantitative studies found that patients wanted imaging of their spine to find a diagnosis of their LBP[24,69,76,77,81]. Hoffman reported that most patients expected their general practitioner to refer them for an x-ray, particularly if they felt that their pain was severe[81]. Amonkar found that more than 60% of participants thought that back x-rays were a positive investigation[24]. Many patients felt that x-rays provided reassurance as well as confirmation of their general practitioner’s diagnosis[38,81]. Furthermore, imaging that showed a physical defect seemed to provide closure[66] and relief[85] for patients and patients sought diagnostic imaging as a means to legitimise their back pain[59,60,77].

Two studies examined the characteristics of patients requesting spinal imaging[56,76]. Wilson found that radiology utilisation was associated with the severity of back pain and a history of osteoporosis[56]. Jenkins reported that increased age, lower education level, non-European cultural background, history of previous spinal imaging and negative beliefs about back pain were associated with a perceived need for imaging[76].

Discussion

This review identified 50 relevant articles that explored patients’ perceived needs for medical services for LBP. Four main areas of perceived need emerged, related to the need for (1) medical practitioners, (2) pharmacotherapy, (3) interventional therapies and (4) diagnostic evaluation. Patients with LBP sought healthcare from medical practitioners to obtain a diagnosis, sickness certification and to receive management options. However, patients were dissatisfied with a biomedical approach to care provided by medical practitioners. Patients saw a need for pharmacotherapy in pain management to facilitate function, however, they had concerns about medication side-effects and a fear of stigmatisation. Of the limited studies that examined the patients’ perceived need for invasive therapies, they reported that patients tend to avoid these treatment modalities. Furthermore, patients had misplaced beliefs about the necessity of imaging, and desired spinal imaging for diagnostic purposes and legitimation of symptoms.

Patients perceive a need for medical practitioners to obtain a diagnosis and strategies to cope with LBP and the associated disability[89],[25,37,38,50,51,5961,67,69,74,7985]. In particular, patients with greater pain and more severe functional limitation sought medical help[58,59,64], thus highlighting the urgent need for more comprehensive and targeted delivery of effective and tailored pain management and coping strategies. In particular, it reinforces the importance of educating patients that in more than 90% of cases LBP cannot be attributed to a pathoanatomic cause, and is thus termed ‘non-specific’. Here, it is critical to reassure patients about their presentation and prognosis. [90]. The patients’ utilisation of medical services for sickness certification and legitimisation of their back pain has also clearly emanated from this review[25,43,5052,60,69,79,84]. This mirrors the complexity of LBP and the widespread impact of the condition on social functioning, financial security and workplace satisfaction.

Patients have areas of dissatisfaction with the medical approach to management of LBP. They have expressed a lack of confidence in general practitioners in the management of their LBP[41,46,47], which may reflect the knowledge gap in primary care settings in LBP management[91,92]. This reinforces the need for training medical practitioners and further targeted education campaigns to upskill clinicians[93,94]. Patients were also displeased with the biomedically-focussed and cursory approach of medical practitioners in managing LBP[37,40,41,4547,51,53,60,84]. This frustration with medical practitioners may stem from the biomedical paradigm used by many healthcare providers, which does not adequately consider the important psychological and social drivers to a pain experience nor address the patients’ need for holistic care[95]. Importantly, reliance on a biomedical approach to diagnosis and care in low back pain presentations is now considered overly reductionist and discordant with contemporary pain science. There is emerging evidence supporting the implementation of tailored therapy, addressing not only the physical aspects but also psychological factors in healthcare delivery for people with chronic LBP: this has been shown to improve health outcomes[96,97]. Despite a body of evidence supporting the biopsychosocial paradigm, practitioners encounter challenges in executing this approach to care[91,98]. In recent years, musculoskeletal Models of Care have been introduced[99101]. These provide evidence-informed strategies for the delivery of patient-centred healthcare, including multidisciplinary pain management clinics, community-based education groups for patients, self-management group and individual programs for patients and carers, and education programs for primary care physicians. These interventions have been shown to improve health outcomes in terms of service delivery, patient satisfaction and health costs[96]. Further research is required to improve their implementation, assess cost effectiveness and promote the long-term sustainability of these approaches to care.

There is a wide spectrum of patient perceived need for pharmacotherapy in the management of LBP. Their needs are in line with current recommendations, with due consideration of potential side effects which require careful monitoring[102105]. This review found conflicting beliefs regarding pharmacotherapy amongst patients, with some expecting medications for LBP management[24,43,48,50,57,67,74,81], whereas others were concerned about medication side-effects and the potential for addiction and desensitisation[4244,48,50,54,65,74]. There is a critical need to rationalise the utilisation of prescription medication for LBP[106] with the recent epidemic of prescription drug misuse, particularly in developed countries[107,108]. The excessive use of opioids is problematic as there is little evidence to support the use of opiates for longer than 12 weeks, there are significant risks of addiction and death[107,109], and substantial costs[110]. This highlights the need for more effective training of medical practitioners in pain management and counselling patients regarding the use of prescription analgesics. Additionally, widespread patient education programs informing patients about the potential risks of pharmacotherapy, particularly opioids, should be provided and may have positive behavioural consequences that can lower the risk of addiction and abuse related to prescription medications[111].

Although some patients perceive a need for invasive interventions to manage LBP, there is limited or inconclusive evidence to support its use[112,113]. In addition to rising costs of pharmacotherapy for LBP, the costs of interventional therapies such as epidural and facet joint injections, as well as spinal surgery have also risen substantially[7]. Despite the widespread use of interventional modalities, this review identified only five studies[44,48,55,70,75] that described patients’ perceived needs for these therapies. These found that patients wanted to avoid interventional therapies such as injections and surgery[44,48,70]. Patients who preferred invasive interventions were more likely to be male, have higher pain levels and a longer duration of symptoms[55,70]. The relationship between their preferences and understanding of the risks and benefits of these procedures was not reported. These studies mainly recruited patients from hospitals, general practices or chiropractic clinics, thus representing a population of patients that have actively sought care for the management of their LBP, and potentially may have more disabling or persistent pain and are self-selected for a biomedically-oriented belief system about the aetiology of their pain. Health system interventions may need to be introduced to limit access to these therapies that lack evidence of effectiveness. Patient education and pain multidisciplinary management programs which embrace a biopsychosocial approach to care may also be used to better equip patients with more appropriate coping strategies for pain and address the patients’ perceived needs for interventional therapies in community-based populations[114].

Finally, many studies found that patients with LBP wanted imaging of their spine[24,69,76,77,81], despite the evidence-based recommendations to limit the use of radiological imaging[610,115], which is inappropriately overused[8]. Patients reported a preference for imaging to find a diagnosis, and some requested imaging to legitimise their back pain[24,38,59,60,66,7678,81]. Patients’ preference for imaging suggests the need for additional public education about the inability to link the experience of pain with a structural pathology in the majority of cases[8,116] and appropriate utilisation of radiology and management of LBP. Public education campaigns have been used to reduce unnecessary radiology imaging[117], which may decrease the enormous economic burden of LBP. Addressing patients’ expectations and perceived needs of radiology utilisation may improve the provider-patient relationship, thus, improving health outcomes.

The results of this review need to be interpreted in light of a number of limitations. First, the included studies were heterogeneous in their study aims, study populations, participant sources, study design and methodology, thus the results of this study need to be interpreted in the context of heterogeneity in source data used. A further limitation of the design of the review is that potentially important differences between studies (e.g. population groups, healthcare settings) may be hidden by virtue of the analysis and reporting method used. Moreover, study populations were predominantly female. Participants were recruited mainly from hospital settings or general practices, rather than from the community. Additionally, many studies were from developed, English-speaking countries. These limitations restrict the generalizability of the results. Furthermore, few studies examined the possible effects of demographic variables such as age, gender, ethnicity, socioeconomic status, other co-morbidities and education on the perceived needs of medical services for LBP. Future studies examining specific subgroups defined by key characterising variables would be informative. Many of the included studies were susceptible to bias and had methodological limitations. However, as this was a scoping review, the main concern relates to a failure to capture populations that were not included and the breadth of perceived needs. Another limitation of this review is that there were no studies that specifically examined patients with acute LBP. Patients with acute LBP may have different perceived needs compared to those with chronic LBP, however, these were not differentiated in the primary papers we retrieved for this review. Therefore, the results from this review cannot be extrapolated to those with acute presentations of LBP. Future studies examining patients’ perceived need for medical services for acute LBP are warranted. Despite these limitations, this review incorporates qualitative and quantitative studies and encompassed four complementary databases to capture the breadth of the topic, and found consistent themes regardless of differences in study populations and methodologies. The data from studies was collated to provide an inclusive and in-depth description of the patient perspective of the medical management of LBP.

Patient expectations inform their use of and satisfaction with healthcare, particularly with conditions driven by symptoms, such as LBP. This review has highlighted the patients’ perceived needs and perceptions of the medical management of LBP and outlined gaps in our current knowledge, as well as areas of mismatch between patients’ perceived needs and evidence-based practice. The National Institute of Health and Care Excellence (NICE) guidelines for LBP acknowledge the importance of “tak(ing) into account the person’s expectations and preferences” in the implementation of evidence-based practice[118]. Moving forward, when formulating clinical practice recommendations, clinicians and guideline panels should collaborate with patient groups, to ensure incorporation of the patient perspective[119]. This may be achieved through a combination of consumer-centred Models of Care, public community education campaigns and enhancing clinicians’ communication skills to convey the appropriate messages. A coordinated educational campaign is required to bring medical management and patient expectations in line with evidence-based practice to optimize patient and health service outcomes.

References

  1. 1. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. (2014) The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 73: 968–974. pmid:24665116
  2. 2. Walker BF, Muller R, Grant WD (2004) Low back pain in Australian adults: prevalence and associated disability. Journal of Manipulative & Physiological Therapeutics 27: 238–244.
  3. 3. Dieleman JL, Baral R, Birger M, Bui A, Bulchis A, Chapin AM, et al. (2016) Us spending on personal health care and public health, 1996–2013. JAMA 316: 2627–2646. pmid:28027366
  4. 4. Koes BW, van Tulder M, Lin C-WC, Macedo LG, McAuley J, Maher C (2010) An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. European Spine Journal 19: 2075–2094. pmid:20602122
  5. 5. NICE (2016) Low back pain and sciatica—draft.
  6. 6. Balagué F, Mannion AF, Pellisé F, Cedraschi C Non-specific low back pain. The Lancet 379: 482–491.
  7. 7. Chou R, Atlas SJ, Stanos SP, Rosenquist RW (2009) Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976) 34: 1078–1093. pmid:19363456
  8. 8. Chou R, Qaseem A, Owens DK, Shekelle P (2011) Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Annals of Internal Medicine 154: 181–189. pmid:21282698
  9. 9. Dagenais S, Tricco AC, Haldeman S (2010) Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. The Spine Journal 10: 514–529. pmid:20494814
  10. 10. Pillastrini P, Gardenghi I, Bonetti F, Capra F, Guccione A, Mugnai R, et al. (2012) An updated overview of clinical guidelines for chronic low back pain management in primary care. Joint Bone Spine 79: 176–185. pmid:21565540
  11. 11. Grimshaw JM, Eccles MP (2004) Is evidence-based implementation of evidence-based care possible? Med J Aust 180: S50–51. pmid:15012580
  12. 12. Grol R (2001) Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care 39: II46–54. pmid:11583121
  13. 13. Ramanathan SA, Hibbert PD, Maher CG, Day RO, Hindmarsh DM, Hooper TD, et al. (2017) CareTrack: Toward Appropriate Care for Low Back Pain. Spine (Phila Pa 1976) 42: E802–e809. pmid:27831965
  14. 14. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. (2018) Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 391: 2368–2383. pmid:29573872
  15. 15. Williams CM, Maher CG, Hancock MJ, McAuley JH, McLachlan AJ, Britt H, et al. (2010) Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med 170: 271–277. pmid:20142573
  16. 16. Gonzalez-Urzelai V, Palacio-Elua L, Lopez-de-Munain J (2003) Routine primary care management of acute low back pain: adherence to clinical guidelines. Eur Spine J 12: 589–594. pmid:14605973
  17. 17. Schers H, Braspenning J, Drijver R, Wensing M, Grol R (2000) Low back pain in general practice: reported management and reasons for not adhering to the guidelines in The Netherlands. The British Journal of General Practice 50: 640–644. pmid:11042916
  18. 18. Martin BI, Turner JA, Mirza SK, Lee MJ, Comstock BA, Deyo RA (2009) Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997–2006. Spine (Phila Pa 1976) 34: 2077–2084. pmid:19675510
  19. 19. Deyo RA, Von Korff M, Duhrkoop D (2015) Opioids for low back pain. BMJ: British Medical Journal 350.
  20. 20. Jenkins HJ, Downie AS, Maher CG, Moloney NA, Magnussen JS, Hancock MJ (2018) Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. Spine J.
  21. 21. Dennis S, Watts I, Pan Y, Britt H (2018) The likelihood of general practitioners referring patients to physiotherapists is low for some health problems: secondary analysis of the Bettering the Evaluation and Care of Health (BEACH) observational study. J Physiother 64: 178–182. pmid:29903595
  22. 22. Lewis J, O'Sullivan P (2018) Is it time to reframe how we care for people with non-traumatic musculoskeletal pain? Br J Sports Med.
  23. 23. Cabana MD, Rand CS, Powe NR, et al. (1999) Why don&#39;t physicians follow clinical practice guidelines?: A framework for improvement. JAMA 282: 1458–1465. pmid:10535437
  24. 24. Amonkar SJ, Dunbar AM (2011) Do patients and general practitioners have different perceptions about the management of simple mechanical back pain? International Musculoskeletal Medicine 33: 3–7.
  25. 25. Skelton AM, Murphy EA, Murphy RJ, O'Dowd TC (1996) Patients' views of low back pain and its management in general practice. British Journal of General Practice 46: 153–156. pmid:8731620
  26. 26. Verbeek J, Sengers M, Riemens L, Haafkens J (2004) Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine 29: 2309–2318. pmid:15480147
  27. 27. Hopayian K, Notley C (2014) A systematic review of low back pain and sciatica patients' expectations and experiences of health care. Spine Journal 14: 1769–1780. pmid:24787355
  28. 28. Arksey H, O'Malley L (2005) Scoping studies: towards a methodological framework. International Journal of Social Research Methodology 8: 19–32.
  29. 29. Armstrong R, Hall BJ, Doyle J, Waters E (2011) ‘Scoping the scope’ of a cochrane review. Journal of Public Health 33: 147–150. pmid:21345890
  30. 30. Levac D, Colquhoun H, O'Brien KK (2010) Scoping studies: advancing the methodology. Implementation Science: IS 5: 69–69. pmid:20854677
  31. 31. Wluka A, Chou L, Briggs A, Cicuttini F (2016) Understanding the needs of consumers with musculoskeletal conditions: Consumers’ perceived needs of health information, health services and other non-medical services: A systematic scoping review. Melbourne: MOVE muscle, bone & joint health.
  32. 32. Papandony MC, Chou L, Seneviwickrama M, Cicuttini FM, Lasserre K, Teichtahl AJ, et al. (2017) Patients' perceived health service needs for osteoarthritis (OA) care: a scoping systematic review. Osteoarthritis Cartilage.
  33. 33. Asadi-Lari M, Tamburini M, Gray D (2004) Patients' needs, satisfaction, and health related quality of life: Towards a comprehensive model. Health and Quality of Life Outcomes 2: 32–32. pmid:15225377
  34. 34. Walsh D, Downe S (2005) Meta-synthesis method for qualitative research: a literature review. J Adv Nurs 50: 204–211. pmid:15788085
  35. 35. Critical Appraisal Skills Programme (2017). CASP (Qualitative Research) Checklist. [online] Available at http://www.casp-uk.net/casp-tools-checklists.
  36. 36. Hoy D, Brooks P, Woolf A, Blyth F, March L, Bain C, et al. (2012) Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement. J Clin Epidemiol 65: 934–939. pmid:22742910
  37. 37. Sanders T, Bie Nio O, Roberts D, Corbett M (2015) Health maintenance, meaning, and disrupted illness trajectories in people with low back pain: a qualitative study. Health Sociology Review 24: 1–14 14p.
  38. 38. Holt N, Pincus T, Vogel S (2015) Reassurance during low back pain consultations with GPS: A qualitative study. British Journal of General Practice 65: e692–e701. pmid:26412846
  39. 39. Yi D, Ryan M, Campbell S, Elliott A, Torrance N, Chambers A, et al. (2011) Using discrete choice experiments to inform randomised controlled trials: an application to chronic low back pain management in primary care. European Journal of Pain 15: 531.e531–510.
  40. 40. Westmoreland JL, Williams NH, Wilkinson C, Wood F, Westmoreland A (2007) Should your GP be an osteopath? Patients' views of an osteopathy clinic based in primary care. Complementary Therapies in Medicine 15: 121–127. pmid:17544863
  41. 41. Toye F, Barker K (2012) Persistent non-specific low back pain and patients' experience of general practice: a qualitative study. Primary Health Care Research & Development 13: 72–84.
  42. 42. Snelgrove S, Edwards S, Liossi C (2013) A longitudinal study of patients’ experiences of chronic low back pain using interpretative phenomenological analysis: Changes and consistencies. Psychology & Health 28: 121–138.
  43. 43. Ong BN, Konstantinou K, Corbett M, Hay E (2011) Patients' own accounts of sciatica: a qualitative study. Spine (Phila Pa 1976) 36: 1251–1256. pmid:21343854
  44. 44. Lyons KJ, Salsbury SA, Hondras MA, Jones ME, Andresen AA, Goertz CM (2013) Perspectives of older adults on co-management of low back pain by doctors of chiropractic and family medicine physicians: a focus group study. BMC Complementary & Alternative Medicine 13: 225.
  45. 45. May S (2007) Patients' attitudes and beliefs about back pain and its management after physiotherapy for low back pain. Physiotherapy Research International 12: 126–135. pmid:17624898
  46. 46. McIntosh A, Shaw CF (2003) Barriers to patient information provision in primary care: patients' and general practitioners' experiences and expectations of information for low back pain. Health Expectations 6: 19–29. pmid:12603625
  47. 47. Layzell M (2001) Back pain management: A patient satisfaction study of services. British Journal of Nursing 10: 800. pmid:11972125
  48. 48. Dima A, Lewith GT, Little P, Moss-Morris R, Foster NE, Bishop FL (2013) Identifying patients' beliefs about treatments for chronic low back pain in primary care: a focus group study. British Journal of General Practice 63: e490–498. pmid:23834886
  49. 49. Cook FM, Hassenkamp AM (2000) Active rehabilitation for chronic low back pain: The patient's perspective. Physiotherapy 86: 61–68.
  50. 50. Coole C, Drummond A, Watson P, Radford K (2010) What Concerns Workers with Low Back Pain? Findings of a Qualitative Study of Patients Referred for Rehabilitation. Journal of Occupational Rehabilitation 20: 472–480. pmid:20373135
  51. 51. Coole C, Watson PJ, Drummond A (2010) Staying at work with back pain: patients' experiences of work-related help received from GPs and other clinicians. A qualitative study. BMC Musculoskeletal Disorders 11: 190. pmid:20799938
  52. 52. Chew CA, May CR (1997) The benefits of back pain. Family Practice 14: 461–465. pmid:9476077
  53. 53. Campbell C, Guy A (2007) `Why Can't They Do Anything for a Simple Back Problem?': A Qualitative Examination of Expectations for Low Back Pain Treatment and Outcome. Journal of Health Psychology 12: 641–652. pmid:17584815
  54. 54. Banbury P, Feenan K, Allcock N (2008) Experiences of analgesic use in patients with low back pain. British Journal of Nursing 17: 1215–1218. pmid:18974689
  55. 55. Franz EW, Bentley JN, Yee PP, Chang KW, Kendall-Thomas J, Park P, et al. (2015) Patient misconceptions concerning lumbar spondylosis diagnosis and treatment. Journal of neurosurgery Spine. 22: 496–502. pmid:25723120
  56. 56. Wilson IB, Dukes K, Greenfield S, Kaplan S, Hillman B (2001) Patients' role in the use of radiology testing for common office practice complaints. Archives of Internal Medicine 161: 256–263. pmid:11176741
  57. 57. Wallace AS, Freburger JK, Darter JD, Jackman AM, Carey TS (2009) Comfortably numb? Exploring satisfaction with chronic back pain visits. Spine Journal: Official Journal of the North American Spine Society 9: 721–728.
  58. 58. Sharma R, Haas M, Stano M (2003) Patient attitudes, insurance, and other determinants of self-referral to medical and chiropractic physicians. American Journal of Public Health 93: 2111–2117. pmid:14652343
  59. 59. Rhodes LA, McPhillips-Tangum CA, Markham C, Klenk R (1999) The power of the visible: The meaning of diagnostic tests in chronic back pain. Social Science & Medicine 48: 1189–1203.
  60. 60. McPhillips-Tangum CA, Cherkin DC, Rhodes LA, Markham C (1998) Reasons for Repeated Medical Visits Among Patients with Chronic Back Pain. Journal of General Internal Medicine 13: 289–295. pmid:9613883
  61. 61. Kawi J (2014) Chronic Low Back Pain Patients' Perceptions on Self-Management, Self-Management Support, and Functional Ability. Pain Management Nursing 15: 258–264. pmid:23232149
  62. 62. Carey TS, Evans AT, Hadler NM, Lieberman G, Kalsbeek WD, Jackman AM, et al. (1996) Acute severe low back pain: a population-based study of prevalence and care-seeking. Spine 21: 339–344. pmid:8742211
  63. 63. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR, et al. (1995) The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. New England Journal of Medicine 333: 913–917. pmid:7666878
  64. 64. Carey TS, Garrett JM, Jackman A, Hadler N (1999) Recurrence and care seeking after acute back pain: results of a long-term follow-up study. North Carolina Back Pain Project. Medical Care 37: 157–164. pmid:10024120
  65. 65. Buchbinder M, Wilbur R, McLean S, Sleath B (2015) "Is there any way I can get something for my pain?" Patient strategies for requesting analgesics. Patient Education and Counseling 98: 137–143. pmid:25468395
  66. 66. Allegretti A, Borkan J, Reis S, Griffiths F (2010) Paired interviews of shared experiences around chronic low back pain: classic mismatch between patients and their doctors. Family Practice 27: 676–683. pmid:20671000
  67. 67. Stisen DB, Tegner H, Bendix T, Esbensen BA (2016) The experience of patients with fear-avoidance belief hospitalised for low back pain-A qualitative study. Disability and Rehabilitation: An International, Multidisciplinary Journal 38: 307–314.
  68. 68. Liddle SD, Gracey JH, Baxter GD (2007) Advice for the management of low back pain: a systematic review of randomised controlled trials. Manual Therapy 12: 310–327. pmid:17395522
  69. 69. Schers H, Wensing M, Huijsmans Z, van Tulder M, Grol R (2001) Implementation barriers for general practice guidelines on low back pain a qualitative study. Spine 26: E348–353. pmid:11474367
  70. 70. Klojgaard ME, Manniche C, Pedersen LB, Bech M, Sogaard R (2014) Patient preferences for treatment of low back pain-a discrete choice experiment. Value in Health 17: 390–396. pmid:24968999
  71. 71. Lærum E, Indahl A, Skouen JS (2006) WHAT IS “THE GOOD BACK-CONSULTATION”? A COMBINED QUALITATIVE AND QUANTITATIVE STUDY OF CHRONIC LOW BACK PAIN PATIENTS’ INTERACTION WITH AND PERCEPTIONS OF CONSULTATIONS WITH SPECIALISTS. Journal of Rehabilitation Medicine (Taylor & Francis Ltd) 38: 255–262. pmid:16801209
  72. 72. Heyduck K, Meffert C, Glattacker M (2014) Illness and treatment perceptions of patients with chronic low back pain: Characteristics and relation to individual, disease and interaction variables. Journal of Clinical Psychology in Medical Settings 21: 267–281. pmid:25100026
  73. 73. Chenot JF, Leonhardt C, Keller S, Scherer M, Donner-Banzhoff N, Pfingsten M, et al. (2008) The impact of specialist care for low back pain on health service utilization in primary care patients: a prospective cohort study. European Journal of Pain 12: 275–283. pmid:17681811
  74. 74. Scheermesser M, Bachmann S, Schamann A, Oesch P, Kool J (2012) A qualitative study on the role of cultural background in patients' perspectives on rehabilitation. BMC Musculoskeletal Disorders 13.
  75. 75. Lacroix A, Jacquemet S, Assal JP (1995) Patients' experiences with their disease: learning from the differences and sharing the common problems. Patient Education & Counseling 26: 301–312.
  76. 76. Jenkins H, Hancock M, Maher C, French S, Magnussen J (2016) Understanding patient beliefs regarding the use of imaging in the management of low back pain. European Journal of Pain 20: 573–580. pmid:26282178
  77. 77. Darlow B, Dean S, Perry M, Mathieson F, Baxter GD, Dowell A (2015) Easy to harm, hard to heal: Patient views about the back. Spine 40: 842–850. pmid:25811262
  78. 78. Slade SC, Molloy E, Keating JL (2009) Stigma Experienced by People with Nonspecific Chronic Low Back Pain: A Qualitative Study. Pain Medicine 10: 143–154. pmid:19222775
  79. 79. Rogers WA (1999) Beneficence in general practice: an empirical investigation. Journal of Medical Ethics 25: 388–393. pmid:10536763
  80. 80. Kirby ER, Broom AF, Sibbritt DW, Refshauge KM, Adams J (2013) Health care utilisation and out-of-pocket expenditure associated with back pain: a nationally representative survey of Australian women. PLoS ONE [Electronic Resource] 8: e83559. pmid:24376716
  81. 81. Hoffmann TC, Del Mar CB, Strong J, Mai J (2013) Patients' expectations of acute low back pain management: implications for evidence uptake. BMC Family Practice 14: 7. pmid:23297840
  82. 82. Crowe M, Whitehead L, Jo Gagan M, Baxter D, Panckhurst A (2010) Self-management and chronic low back pain: a qualitative study. Journal of Advanced Nursing 66: 1478–1486. pmid:20492018
  83. 83. Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S (2013) The enduring impact of what clinicians say to people with low back pain. Annals of Family Medicine 11: 527–534. pmid:24218376
  84. 84. Borkan J, Reis S, Hermoni D, Biderman A (1995) Talking about the pain: a patient-centered study of low back pain in primary care. Social Science & Medicine 40: 977–988.
  85. 85. Slade SC, Molloy E, Keating JL (2009) `Listen to me, tell me': a qualitative study of partnership in care for people with non-specific chronic low back pain. Clinical Rehabilitation 23: 270–280. pmid:19218301
  86. 86. Sanderson KB, Roditi D, George SZ, Atchison JW, Banou E, Robinson ME (2012) Investigating patient expectations and treatment outcome in a chronic low back pain population. Journal of Pain Research 5: 15–22. pmid:22328831
  87. 87. Sanders T, Dunn K, Konstantinou K, Hay E (2013) Managing sciatica in the physiotherapy consultation: A qualitative observation and interview study. Rheumatology (United Kingdom) 52: i99–i100.
  88. 88. Toye F, Barker K (2010) ‘Could I be imagining this?’–the dialectic struggles of people with persistent unexplained back pain. Disability & Rehabilitation 32: 1722–1732.
  89. 89. Bunzli S, Watkins R, Smith A, Schütze R, O'Sullivan P (2013) Lives on Hold: A Qualitative Synthesis Exploring the Experience of Chronic Low-back Pain. Clinical Journal of Pain 29: 907–916. pmid:23370072
  90. 90. Deyo RA, Weinstein JN (2001) Low Back Pain. New England Journal of Medicine 344: 363–370. pmid:11172169
  91. 91. Bishop FL, Dima AL, Ngui J, Little P, Moss-Morris R, Foster NE, et al. (2015) "Lovely Pie in the Sky Plans": A Qualitative Study of Clinicians' Perspectives on Guidelines for Managing Low Back Pain in Primary Care in England. Spine (Phila Pa 1976) 40: 1842–1850. pmid:26571064
  92. 92. Scott NA, Moga C, Harstall C (2010) Managing low back pain in the primary care setting: The know-do gap. Pain Research & Management: The Journal of the Canadian Pain Society 15: 392–400.
  93. 93. Slater H, Davies SJ, Parsons R, Quintner JL, Schug SA (2012) A Policy-into-Practice Intervention to Increase the Uptake of Evidence-Based Management of Low Back Pain in Primary Care: A Prospective Cohort Study. PLOS ONE 7: e38037. pmid:22662264
  94. 94. Briggs AM, Slater H, Smith AJ, Parkin-Smith GF, Watkins K, Chua J (2013) Low back pain-related beliefs and likely practice behaviours among final-year cross-discipline health students. Eur J Pain 17: 766–775. pmid:23139051
  95. 95. Coudeyre E, Tubach F, Rannou F, Baron G, Coriat F, Brin S, et al. (2007) Fear-avoidance beliefs about back pain in patients with acute LBP. The Clinical Journal of Pain 23: 720–725. pmid:17885352
  96. 96. Speerin R, Slater H, Li L, Moore K, Chan M, Dreinhöfer K, et al. Moving from evidence to practice: Models of care for the prevention and management of musculoskeletal conditions. Best Practice & Research Clinical Rheumatology 28: 479–515.
  97. 97. Vibe Fersum K, O'Sullivan P, Skouen JS, Smith A, Kvale A (2013) Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial. Eur J Pain 17: 916–928. pmid:23208945
  98. 98. Synnott A, O’Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, O'Sullivan K Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. Journal of Physiotherapy 61: 68–76. pmid:25812929
  99. 99. Briggs AM, Bragge P, Slater H, Chan M, Towler SC (2012) Applying a Health Network approach to translate evidence-informed policy into practice: a review and case study on musculoskeletal health. BMC Health Serv Res 12: 394. pmid:23151082
  100. 100. Briggs AM, Jordan JE, Speerin R, Jennings M, Bragge P, Chua J, et al. (2015) Models of care for musculoskeletal health: a cross-sectional qualitative study of Australian stakeholders' perspectives on relevance and standardised evaluation. BMC Health Serv Res 15: 509. pmid:26573487
  101. 101. Briggs AM, Towler SC, Speerin R, March LM (2014) Models of care for musculoskeletal health in Australia: now more than ever to drive evidence into health policy and practice. Aust Health Rev 38: 401–405. pmid:25086678
  102. 102. Roelofs PDDM Deyo RA, Koes BW Scholten RJPM, van Tulder MW (2008) Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database of Systematic Reviews.
  103. 103. Enthoven WTM, Roelofs PDDM, Deyo RA, van Tulder MW, Koes BW (2016) Non-steroidal anti-inflammatory drugs for chronic low back pain. Cochrane Database of Systematic Reviews.
  104. 104. Chaparro LE, Furlan AD, Deshpande A, Mailis-Gagnon A, Atlas S, Turk DC (2013) Opioids compared to placebo or other treatments for chronic low-back pain. Cochrane Database of Systematic Reviews.
  105. 105. van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM (2003) Muscle relaxants for non-specific low-back pain. Cochrane Database of Systematic Reviews.
  106. 106. Walker BF, Muller R, Grant WD (2003) Low back pain in Australian adults: the economic burden. Asia-Pacific Journal of Public Health 15: 79–87. pmid:15038680
  107. 107. Martell BA, O'Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR, et al. (2007) Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction. Annals of Internal Medicine 146: 116–127. pmid:17227935
  108. 108. Zgierska A, Miller M, Rabago D (2012) PAtient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA 307: 1377–1378. pmid:22474199
  109. 109. Rudd RA, Seth P, David F, L S (2016) Increases in Drug and Opioid-Involved Overdose Deaths—United States, 2010–2015. MMWR Morb Mortal Wkly Rep.
  110. 110. Birnbaum HG, White AG, Schiller M, Waldman T, Cleveland JM, Roland CL (2011) Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Med 12: 657–667. pmid:21392250
  111. 111. Hero JO, McMurtry SM, Benson J, R B (2016) Discussing Opioid Risks With Patients to Reduce Misuse and Abuse: Evidence from 2 Surveys. Annals Family Medicine 14: 575–577.
  112. 112. Staal JB, de Bie R, de Vet HCW, Hildebrandt J, Nelemans P (2008) Injection therapy for subacute and chronic low-back pain. Cochrane Database of Systematic Reviews.
  113. 113. Cheriyan T, Harris B, Cheriyan J, Lafage V, Spivak JM, Bendo JA, et al. (2015) Association between compensation status and outcomes in spine surgery: a meta-analysis of 31 studies. The spine journal: official journal of the North American Spine Society 15: 2564–2573.
  114. 114. Loeser JD, Cahana A (2013) Pain medicine versus pain management: ethical dilemmas created by contemporary medicine and business. Clin J Pain 29: 311–316. pmid:23462285
  115. 115. Koes BW, van Tulder MW, Ostelo R, Kim Burton A, Waddell G (2001) Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine (Phila Pa 1976) 26: 2504–2513; discussion 2513–2504. pmid:11707719
  116. 116. Steffens D, Hancock MJ, Maher CG, Williams C, Jensen TS, Latimer J (2014) Does magnetic resonance imaging predict future low back pain? A systematic review. Eur J Pain 18: 755–765. pmid:24276945
  117. 117. French SD, Green S, Buchbinder R, Barnes H (2010) Interventions for improving the appropriate use of imaging in people with musculoskeletal conditions. Cochrane Database of Systematic Reviews.
  118. 118. Savigny P, Watson P, Underwood M (2009) Early management of persistent non-specific low back pain: summary of NICE guidance. BMJ 338: b1805. pmid:19502217
  119. 119. Montori VM, Brito J, Murad M (2013) The optimal practice of evidence-based medicine: Incorporating patient preferences in practice guidelines. JAMA 310: 2503–2504. pmid:24165826