Acute low back pain management in general practice: uncertainty and conflicting certainties

Ben Darlow, Sarah Dean, Meredith Perry, Fiona Mathieson, G David Baxter, Anthony Dowell
Family Practice 2014, 31 (6): 723-32

BACKGROUND: Low back pain (LBP) is a significant health problem and common reason to visit the GP. Evidence suggests GPs experience difficulty applying evidence-based guidelines.

OBJECTIVE: Explore GPs' underlying beliefs about acute LBP and how these influence their clinical management of patients.

METHODS: Eleven GPs from one geographical region within New Zealand were recruited by purposive sampling. Audio recordings of semi-structured qualitative interviews were transcribed verbatim. Data were analysed with an Interpretive Description framework.

RESULTS: Four key themes emerged related to the causes of acute LBP, GP confidence, communicating diagnostic uncertainty and encouraging movement and activity. Acute LBP was seen as a direct representation of tissue injury, consequently the assessment and management of patients' attitudes and beliefs was not a priority. Participants' confidence was decreased due to a perceived inability to diagnose or influence the tissue injury. Despite this, diagnoses were provided to patients to provide reassurance and meet expectations. Guideline recommendations regarding activity conflicted with a perceived need to protect damaged tissue, resulting in reported provision of mixed messages about the need to be both active and careful.

CONCLUSIONS: GPs' initial focus upon tissue injury during acute care, and providing a diagnostic label, may influence patients' subsequent alignment with a biomedical perspective and contribute to consultation conflict and patients' perception of blame when discussion of psychosocial influences is introduced. Demonstrating the relevance of the biopsychosocial model to acute LBP may improve GPs' alignment with guidelines, improve their confidence to manage these patients and ultimately improve outcomes.

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