Low back pain in primary care

Dr Peter Kent

Most low back pain (85%) is classified as nonspecific low back pain (NSLBP) and there is large variation in its management. One view is that NSLBP cannot be diagnosed more specifically and should be treated generically. However, most primary health care practitioners believe that there are sub-groups of NSLBP based upon symptoms and signs that respond differently to interventions.
There is some preliminary evidence that treating patients differentially does improve patient outcomes but little agreement on sub-group characteristics. The aim of this cohort study is to identify whether sub-groups are empirically recognisable and if they have different prognostic and treatment outcomes.

This project will track the progression of LBP from initial presentation to outcome and develop predictive formulae to allow clinicians to identify sub-groups of people with NSLBP who are likely to recover slowly, respond differentially to therapy options or derive little benefit from therapy. Identifying patients with a poor probability of recovery early in the course of the condition may circumvent subjecting these patients to treatments that have little or no chance of success, and may facilitate development of strategies with higher likelihood of success. Identifying people with very good prognoses may indicate that intervention is unnecessary.

If sub-groups display significantly different prognoses, subsequent studies into sub-group specific predictive factors will seek to identify clinically modifiable risk factors. If sub-groups respond differently to interventions, subsequent studies will seek to identify optimal sub-group specific interventions. Both research directions could lead to improved patient outcomes. If the notion of sub-grouping in LBP does not have prognostic validity or treatment choice utility, then its continued practice will be difficult to defend. Either way, clinical practice should be advanced and greater uniformity of assessment practice encouraged.

The use in this study of an evidence-based standardised assessment procedure that captures broad biopsychosocial information, and the use of data-mining with sub-group outcome validation are unprecedented in LBP research.

Publications arising from preliminary work for this study:
Kent P, Keating JL. Do primary-care clinicians think that non-specific low back pain is one condition? Spine 2004 29(9):1022-1031.

Kent P, Marks D, Pearson W, Keating JL. Does giving clinicians treatment choice improve the outcomes of randomised controlled trials of manual therapy for non-specific low back pain? - A systematic review and meta-analysis. Journal of Manipulative and Physiological
Therapeutics 2005 28:1-11.

Kent P, Keating JL. Classification in non-specific low back pain - what methods do primary care clinicians currently use? Spine 2005 30:1433-1440.

Kent P, Keating JL. The epidemiology of low back pain in primary care. Chiropractic and Osteopathy/BMC 13: 13 doi:10.1186/1746-1340-13-13

Kent P, Keating JL. Predictors of poor-recovery in recent-onset non-specific low back pain:
Systematic review. In revision.

Kent P, Keating JL, Allen M, Morelli L. Assessing change in low back pain: The relationship between change in physical impairment, pain, activity limitation and fear-avoidance beliefs. In revision.

Kent P. Clinical rule predicts patients likely to benefit from spinal manipulation. Critical appraisal and commentary for Australian Journal of Physiotherapy. 2005 51:56