Why less is more when managing low back pain in the ED

Associate Professor Liz Marles*, Clinical Director at the Australian Commission on Safety and Quality in Health Care, explains why it’s time for a cultural shift in our approach to managing back pain.

When you mention low back pain, everyone has a story. If you’re an emergency physician or emergency nurse, there’s a high probability you’ve treated a patient with back pain — the condition is one of the top five presentations to emergency departments.¹ There’s also a high likelihood that you know a family member, friend or colleague who has suffered low back pain.

The release of Australia’s first Low Back Pain Clinical Care Standard in September to help with the assessment and early management of acute low back pain episodes has been applauded across healthcare disciplines and among consumers. The standard is seen as a significant leap forward in addressing this common yet often distressing and debilitating condition.

The burden of low back pain

In Australia, low back pain is the leading cause of disability burden, and is the top reason for lost work productivity and early retirement.^2,3 One in six Australians report back pain⁴ and it costs the Australian health system $4.8 billion annually⁵. The condition poses a significant burden to emergency departments, accounting for up to 2% of all attendances and requiring an average length of stay between 4 and 5 hours.⁶

Over time, there has been a marked shift in recommended treatment for low back pain. The use of imaging, bed rest, pain medicines and surgery are now accepted as having a limited role in managing most people with this condition. Current evidence shows that providing patient education and advice, as well as promoting self-management and physical activity, are more effective.⁷

While we now have a good understanding for how low back pain should be managed, many people continue to miss out on recommended care or receive care that is not optimal.^7,8 A recent systematic review of 195,000 patients across seven countries, including Australia, found that around one in three patients with low back pain presenting to the emergency department received referral for imaging and up to 60% were prescribed opioids.⁹

A road map for clinical care

The Australian Commission on Safety and Quality in Health Care (the Commission) developed the Low Back Pain Clinical Care Standard with a focus on early management in emergency departments and primary care. The standard provides practitioners with a ‘road map’ to help patients manage low back pain episodes and reduce their chance of ongoing problems.

The standard comprises eight evidence-based quality statements describing what best practice care should entail (see Box 1). These include reserving imaging for serious underlying pathology and the judicious use of pain medicines.

The Commission has produced a ‘Quick guide for emergency departments’ providing an overview of the care described in the clinical care standard, with key actions and communication tips for ED physicians (see Figure 1).

Use pain medicines judiciously

Noteworthy in the standard is a shift in messaging around the role of pain medicines. Clinicians are encouraged to advise patients that pain medicines should be used to support activity, rather than to eliminate their pain.

The standard recommends avoiding anticonvulsants, benzodiazepines and antidepressants altogether and advises that opioid analgesics should only be used in carefully selected patients, at the lowest dose for the shortest duration possible.

Importantly in the emergency department setting, simple analgesics and non-drug approaches should be used whenever possible. If an opioid is prescribed, the duration of therapy should be explained to the patient and included in the discharge summary, with the goal of avoiding prolonged use.

Reserve imaging for serious underlying pathology

Concerns about the potential overuse of imaging of the lumbar spine have been expressed for some time. The standard advocates that imaging should be reserved for patients with suspected serious pathology as routine imaging does not improve patient outcomes.¹⁰

Communication around imaging is key, and the standard offers practical communication tips for clinicians on how to explain and reassure patients. Where a potentially serious cause has been ruled out, it is important to discuss expectations of imaging and the limited role of scans in diagnosing low back pain.

Patients should also be advised that incidental findings are very common in people without pain and are usually a normal feature of ageing.

A consistent approach

Research investigating usual care delivered for low back pain has shown there are numerous opportunities to provide patients with better care.⁹ Consistent messaging and education by all clinicians involved in a patient’s care are key to dispelling myths and supporting shared decision-making.

It is heartening that the new clinical care standard has been endorsed by 17 key professional and consumer health organisations, including the Australian College of Emergency Medicine and College of Emergency Nursing Australasia.

The standard supports practitioners and health service organisations to deliver effective care for low back pain patients, who may be treated across different healthcare disciplines and often receive conflicting advice. People with back pain may seek care from emergency physicians, general practitioners, as well as allied health clinicians such as physiotherapists and chiropractors.

With a consistent approach and reassuring messaging, we can work together to remove barriers and prevent this common and sometimes debilitating condition from becoming a long-term problem for many Australians.

Read the standard and download resources at: safetyandquality.gov.au/lowbackpain-ccs

Low Back Pain Clinical Care Standard — Quality statements Initial clinical assessment Psychosocial assessment Reserve imaging for suspected serious pathology Patient education and advice Encourage self-management and physical activity Physical and/or psychological interventions Judicious use of pain medicines Review and referral Read the full quality statements at safetyandquality.gov.au/lowbackpain-ccs.

This article was developed with Christina Lane and Alice Bhasale from the Commission’s Clinical Care Standards team.

*Associate Professor Liz Marles is Clinical Director at the Australian Commission on Safety and Quality in Health Care and guided the development of the Low Back Pain Clinical Care Standard and chaired the Topic Working Group. She provides strategic leadership on work related to primary and community health care. A/Prof Marles is a general practitioner at Hornsby-Brooklyn GP Unit, with a special interest in chronic disease management, mental health and Aboriginal health, and a strong focus on holistic and preventative care.

References

^{1. Australian Institute of Health and Welfare. Australian hospital statistics: Emergency department care 2020–21. Table 4.9: The 20 most common principal diagnoses for emergency department presentations. AIHW; 2022.}

^{2. Schofield DJ, et al. Labor force participation and the influence of having back problems on income poverty in Australia. Spine 2012.}

^{3. Schofield DJ, et al. Lost productive life years caused by chronic conditions in Australians aged 45–64 years, 2010–2030. Med J Aust. 2015.}

^{4. Australian Institute of Health and Welfare. Back problems. AIHW; 2020.}

^{5. Arthritis and Osteoporosis Victoria. A problem worth solving. Arthritis and Osteoporosis Victoria., 2013.}

^{6. Lovegrove, M.T. et al. Analysis of 22,655 presentations with back pain to Perth emergency departments over five years, International Journal of Emergency Medicine, 2011.}

^{7. Foster NE, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018.}

^{8. Buchbinder R, et al. Low back pain: a call for action. Lancet 2018.}

^{9. Kamper SJ, et al. What is usual care for low back pain? A systematic review of health care provided to patients with low back pain in family practice and emergency departments. Pain 2020.}

^{10. Chou R, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet 2009.}