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“Lovely pie in the sky plans”: A qualitative study of clinicians’ perspectives on guidelines
for managing low back pain in primary care in England
F.L. Bishop PhD *1,2, A.L. Dima PhD 2,3, J. Ngui BM 2, P. Little FMedSci 2, R. Moss-Morris PhD 4,
N. E. Foster DPhil 5, G.T. Lewith MRCGP 2
*Corresponding author. Tel: +44 (0)23 8059 9020. Fax: +44 (0)23 8059 4597. Email:
1 Centre for Applications of Health Psychology, Faculty of Social and Human Sciences,
Building 44 Highfield Campus, University of Southampton, Southampton SO17 1BJ United
Kingdom.
2 Department of Primary Care and Population Sciences, University of Southampton,
Aldermoor Health Centre, Aldermoor Close, Southampton SO16 5ST.
3 University of Amsterdam, Department of Communication Science, Amsterdam School of
Communication Research ASCoR, Kloveniersburgwal 48,1012CX Amsterdam, The
Netherlands.
4 Health Psychology Section, Psychology Department, Institute of Psychiatry, Kings College
London, 5th floor Bermondsey Wing, Guy’s Hospital Campus, London Bridge, London SE1
9RT.
5 Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health
Sciences, Keele University, Keele, Staffordshire ST5 5BG.
Funding
1
This paper presents independent research funded by the National Institute for Health
Research (NIHR) School of Primary Care Research (Grant Reference Number 75). Time from
NE Foster was supported through an NIHR Research Professorship (NIHR-RP-011-015). The
views expressed are those of the authors and not necessarily those of the NHS, the NIHR or
the Department of Health. FLB’s post was funded by Arthritis Research UK (Career
Development Fellowship 18099).
The study sponsors and funders had no role in study design; in the collection, analysis, and
interpretation of data; in the writing of the report; or in the decision to submit the article for
publication.
Ethical Approval
Oxfordshire Research Ethics Committee A approved this study (reference 10/H0604/88).
Acknowledgements
We thank the participants for sharing their experiences, the Primary Care Research Network
who helped to recruit the participants, and Clare McDermott and Saima Ali for undertaking
some of the interviews.
Word Counts
Word count main text only: 2700
Number of tables: 5; Number of figures: 0
2
Précis
Qualitative interviews with 53 primary care clinicians explored their approach to managing
patients with low back pain. Analysis showed that national clinical guidelines are one,
relatively peripheral, influence on clinical decision-making and identified reasons for this.
Specific recommendations are made for how these guidelines could become more clinically
relevant.
Key Points
This study shows how the NICE guidelines for managing low back pain in primary care are one, relatively peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists, physiotherapists, osteopaths, and nurses.
We suggest that the NICE guidelines are such a peripheral influence because they do not resonate with clinicians’ day-to-day experience of providing care for individual patients within organisational constraints.
When they are revised, the NICE guidelines for low back pain could be made more relevant to clinicians by: ensuring terminology reflects that used in clinical practice; dispelling the image of guidelines as rigid and prohibiting patient-centred care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended therapies; and better ensuring commissioning of guideline-recommended treatments for National Health Service (NHS) patients.
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Structured Abstract
Study Design: Qualitative study in south-west England primary care.
Objective: To clarify the decision-making processes that result in the delivery of particular
treatments to patients with low back pain (LBP) in primary care and to examine clinicians’
perspectives on the English National Institute for Health and Care Excellence (NICE) clinical
guidelines for managing LBP in primary care.
Summary of Background Data: Merely publishing clinical guidelines is known to be
insufficient to ensure their implementation. Gaining an in-depth understanding of clinicians’
perspectives on specific clinical guidelines can suggest ways to improve the relevance of
guidelines for clinical practice.
Methods: We conducted semi-structured interviews with 53 purposively-sampled clinicians.
Participants were: 16 General Practitioners (GPs), 10 chiropractors, 8 acupuncturists, 8
physiotherapists, 7 osteopaths, and 4 nurses, from the public sector (20), private sector (21),
or both (12). We used thematic analysis.
Results: Official guidelines comprised just one of many inputs to clinical decision-making.
Clinicians drew on personal experience and inter-professional networks and were
constrained by organisational factors when deciding which treatment to prescribe, refer for,
or deliver to an individual patient with LBP. Some found the guideline terminology - “non-
specific LBP” - unfamiliar and of limited relevance to practice. They were frustrated by
disparities between recommendations in the guidelines and the real-world situation of short
consultation times, difficult-to-access specialist services and sparse commissioning of
guideline-recommended treatments.
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Conclusion: The NICE guidelines for managing LBP in primary care are one, relatively
peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists,
physiotherapists, osteopaths, and nurses. When revised, these guidelines could be made
more clinically relevant by: ensuring guideline terminology reflects clinical practice
terminology; dispelling the image of guidelines as rigid and prohibiting patient-centred care;
providing opportunities for clinicians to engage in experiential learning about guideline-
recommended complementary therapies; and commissioning guideline-recommended
treatments for public sector patients.
Keywords
clinical guidelines; clinical decision-making; primary health care; low back pain; qualitative
research; commissioning
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Introduction
Modern healthcare must reconcile evidence-based scientific medicine with person-centred
clinical medicine, to develop “evidence-informed individualised care”.1 Within this context
clinical guidelines are developed at some expense through synthesising scientific evidence
and establishing expert consensus. This study examines the role of guidelines for the primary
care management of low back pain (LBP) which eludes definitive treatment and is the
leading global cause of years lived with disability.2-7 In 2009, the English National Institute for
Health and Care Excellence (NICE) published clinical guidelines on managing persistent, non-
specific low back pain (PNS-LBP) in primary care.8;9 These guidelines sparked debate,10-16
recommended previously-contested treatments (e.g. acupuncture),17-22 and are currently
being updated. They recommended keeping diagnosis under review and using a
combination of front-line treatments while considering patients’ preferences. They are
broadly similar to European23 and American24 recommendations25 (Supplemental Digital
Content 1 compares these recommendations).
Research suggests that following recommendations based on best evidence
improves patient outcomes,26-31 e.g., physiotherapists using recommended active rather than
passive treatments for acute LBP achieved better clinical outcomes more cheaply.26
However, clinical practice often diverges from guidelines.28;32-42 Clinicians unfamiliar with
guidelines are unlikely to implement them.43 Controversial guidelines, those with indirect or
vague wording, and/or those requiring major changes are less likely to be implemented.44;45
Clinicians may diverge from guidelines when they (a) individualise treatment according to
their perceptions of patients’ characteristics, treatment histories, and/or treatment
preferences, (b) hold biomedically-oriented pain cognitions, or (c) prioritise therapeutic
relationships.46-49;49-53 Whatever individual clinicians believe, the fundamentally social nature
of clinical practice can further marginalise guidelines.54
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Merely publishing clinical guidelines is insufficient to ensure their implementation54-
56 and guidelines should be viewed in the context of clinical practice.54 LBP studies have
explored implementation of physiotherapy guidelines33 and specific treatment
recommendations28;40 but not the NICE guidelines. Therefore, we aimed to 1) clarify the
decision-making processes that lead primary care clinicians to deliver particular treatments
to LBP patients, and 2) examine clinicians’ perspectives on the NICE clinical guidelines for
LBP in primary care.
Materials and Methods
Qualitative Data Collection
We identified potential participants in South-West England in 2011 via the Primary Care
Research Network South-West and professional registers. Primary care clinicians consulted
by at least one patient with PNS-LBP within 6 months received written invitations. We
selected a maximum variation sample from 83 replies based on characteristics in Table 1.
Four interviewers conducted semi-structured telephone (48) or face-to-face (5)
interviews to elicit clinicians’ accounts of decision-making and views on clinical guidelines for
LBP in primary care (mean duration 43 minutes, range 19-109 minutes). To reduce social
desirability bias interviewers were non-clinicians, recruitment materials did not emphasise
guidelines and interview introductions were neutral: “...we are interested in finding out all
about how you manage patients with LBP and what you think about the various treatment
options.” Informed consent was obtained before digitally audio-recording interviews,
7
subsequently transcribed verbatim and anonymised. Interviews and analysis proceeded
iteratively.
Qualitative Analysis
We used thematic analysis57 with open coding and constant comparison58 in NVivo9.59 Three
authors collaboratively conducted the analysis. We listened to audio-recordings and
repeatedly read transcripts before categorizing meaning units (utterances that express a
single meaning) into: PNS-LBP definitions, clinical management, decision-making, NICE
guidelines, NICE-recommended treatments/referrals, and other treatments. We reviewed
the categorized meaning units within the context of the original interviews and coded them
inductively, generating descriptive labels. Coded data were compared within and across
codes and categories, very similar codes were merged, and disjointed codes were split. We
wrote memos58 describing analytic decisions. We diagrammed codes, grouped together
codes related to the same processes and reviewed these to identify and name emerging
themes. These emerging themes were discussed with other team members with diverse
backgrounds to aid interpretation (e.g. health psychology, physiotherapy, complementary
alternative medicine - CAM, general practice). We reviewed themes against transcripts to
ensure fit and explored inter-professional similarities and differences. Finally, we mapped
themes related to the NICE guidelines against decision-making themes. Illustrative
anonymized quotes were selected to provide typical examples of themes; some atypical
quotes are presented to demonstrate diversity. Below, “CAM practitioners” refers to
osteopaths, chiropractors, and acupuncturists, although many physiotherapists also deliver
manual therapy and acupuncture.
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Results
Decisions about which treatment to prescribe, refer, or deliver to an individual patient were
made within local social and organisational structures. National clinical guidelines were
merely one relatively peripheral influence. Clinicians’ views of their professional identity and
expertise led different professional groups to focus on slightly different clinical decisions
(Table 2). Regardless of which decisions clinicians focussed on, four overarching themes
captured their accounts. Each theme suggests why clinical guidelines and the practice of
clinical work can diverge and identifies opportunities for better connecting evidence-based
guidelines and practice.
Identifying the Problem: Terminology and Diagnosis
NICE define PNS-LBP as tension, soreness and/or stiffness in the lower back region, not
caused by malignancy, infection, fracture, inflammatory disorders, nerve root compression,
and recurrent or persistent for at least 6 weeks but not longer than 12 months.8;9
Participants generally understood that “non-specific LBP” refers to musculoskeletal LBP with
no serious underlying pathology or nerve root pain; many equated it with “simple” or
“mechanical” LBP. The term “PNS-LBP” was perceived differently.
As shown in Table 3, some aspects of “PNS-LBP” were perceived as helpful but
overall this term was not perceived as particularly relevant by clinicians. Some GPs and
nurses saw “PNS-LBP” as honest but of limited use for communicating with patients and/or
colleagues. GPs and nurses also considered the timeframe useful for prompting more
intensive interventions aiming to prevent progression to chronic pain. However, almost all
clinicians struggled with the idea of pain being positively diagnosed as “non-specific”. GPs
and nurses typically relied on history-taking and rarely undertook the clinical examinations 9
or investigations they perceived valuable to rule out serious pathology or nerve root pain.
Many also felt “non-specific LBP” was an unfamiliar term that lacked information and was
thus unsatisfactory for patients.
Physiotherapists and CAM practitioners saw “PNS-LBP” as an inferior diagnosis
encompassing excessive clinical variation and insufficient precision rendering it incapable of
informing treatment. Indeed, physiotherapists and CAM practitioners described performing
comprehensive clinical examinations and taking detailed histories, ascertaining specific
anatomical and physiological features (e.g. muscle spasm), pain intensity, impact on
patient’s activities and sleep, likely cause(s), and duration. Further investigations (e.g.
diagnostic ultrasound, x-ray) were used sparingly to exclude suspected serious pathologies.
Physiotherapists and CAM practitioners used their professional theoretical frameworks to
develop a detailed aetiological model of a patient’s LBP and formulate an individualised
treatment plan; the term “PNS-LBP” was not perceived as facilitating this.
Overall, many clinicians found the label “PNS-LBP” had little relevance to their
clinical practice. A fundamental disconnect thus exists between the terminology on the front
cover of the NICE guidelines and clinicians’ preferred ways of working. However, participants
did not suggest a preferable alternative title.
Knowing the Patient
Clinicians described taking individual and/or family histories, performing clinical
examinations, attending to patients’ age and gender and exploring patients’ working life (e.g.
profession/job, economic situation), lifestyle (e.g. sports-player, sedentary), and mental
health (e.g. anxiety, depression). This knowledge was used to tailor clinical management.
10
“The way I might treat a 20 year old rugby player would be very different to the way
I would treat an 80 year old lady, very different.” (WH, female chiropractor, private
practice)
“Certainly if someone wants to see a physiotherapist and is keen to be part of that
process then I would refer early to physio[therapist].” (TA, female GP, NHS)
Thus clinicians were broadly consistent with the guideline’s recommendation to consider
patient preferences. However, they did not recognise this convergence because they
mistakenly perceived the guidelines as a rigid treatment pathway that was inconsistent with
individually tailored care.
“I think every treatment plan needs to be tailored really to the patient, and in spite
of NICE, in spite of everyone’s efforts, there isn’t a single pathway or plan that suits
everyone.” (RO, male GP, NHS)
Knowing the Treatment
Clinicians viewed treatments primarily in terms of perceived effectiveness but also discussed
mechanisms of action, adverse effects, and contraindications. When delivering treatment,
knowledge was primarily based on professional clinical experience and/or training. When
making referrals or recommendations, knowledge was based on more diverse sources.
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Sources of perceived “abstract” information (e.g. theoretical literature, “evidence-base”,
guidelines) appeared to have little influence.
Clinicians oriented to but did not universally accept the pervasive discourse of
evidence-based healthcare. Some appeared to embrace evidence-based healthcare while
others resisted it, portraying the evidence base as shifting and inconsistent and therefore of
limited practical use (Table 4 presents quotes). The latter clinicians explicitly reflected on
how constructs like “evidence” as communicated through guidelines were less important
than experiential learning for clinical practice. Indeed, experiential sources of knowledge
including personal experience, colleague’s experiences, and patients’ experiences, were
generally highly valued and influential.
Feeling knowledgeable allowed clinicians to deliver a treatment or refer a patient
on. Perceived lack of knowledge meant a treatment was not considered, even if it was
guideline-recommended. However, some practitioners thought the NICE guidelines might
enhance awareness of effective and ineffective treatments, validating and/or slightly
extending existing practices. The guidelines’ coverage of diverse treatments was thought to
encourage patients and practitioners to consider diverse options and to help practitioners
explain why certain treatments (e.g. TENS) were not prescribed. CAM practitioners felt the
guidelines helped to legitimise their practices for mainstream medical and public audiences.
Even if clinicians perceived the NICE guidelines as novel and potentially helpful, they
did not describe changing practice in response to them. This seemed to be primarily due to
constraints on NHS service provision.
Working within Organisational Constraints
12
Clinicians discussed the challenges of working within organisational constraints including
limited NHS resources (Table 5 shows illustrative quotes). These constraints seemed
particularly important when usually-effective initial pain management and education was
unsuccessful. Referrals for physiotherapy were described as routinely available (although
waiting times varied) and clinicians valued and praised those services which were available,
helpful, and accessible to their patients. However, others highlighted disparities between
the NICE-recommended care pathway and the real-world situation of short consultation
times, difficult-to-access specialist services and long waiting lists. Furthermore, GPs and
nurses were deterred from referring patients to services such as pain management
(incorporating CBT), acupuncture, chiropractic and osteopathy, by a perceived lack of NHS
services and/or a lack of familiarity with local providers. Few were aware that patients might
receive manual therapy and/or acupuncture from physiotherapists. For many the only NHS-
funded option after physiotherapy was to refer to a pain management clinic, which could be
associated with high NHS costs, long waiting lists, and resource implications for patients (e.g.
travel).
When considering referring to CAM practitioners many clinicians emphasised
variability between practitioners and the importance of referring to a known clinician of
good repute. Clinicians with multi-disciplinary networks of local colleagues referred patients
to trusted individuals within those networks. Without such networks clinicians were
reluctant to advise patients.
“I think a lot of the problem here is the practitioner you see, isn't it, how qualified
they are and so on, and patients have to judge that for themselves, which is why I
don't refer actively or recommend anybody.” (GO, female GP, NHS)
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Discussion
Our analysis illustrated how clinicians select treatments based on knowing the individual
patient, knowing about their patient’s back pain, and knowing about common treatment
options; these processes can be facilitated and constrained by organisational factors. The
NICE guidelines for PNS-LBP were a peripheral influence on these decision-making processes
and we found four key explanations for this. One, the terminology in the guidelines (PNS-
LBP) does not resonate with clinical practice. Many clinicians did not value or use the
adjective “non-specific” and instead sought a more nuanced understanding to guide
treatment. Physiotherapists and CAM practitioners described trying to identify more specific
cause(s) of a patient’s LBP before formulating treatment plans. Two, clinicians strive to tailor
treatment to individuals and often attend to patients’ preferences. However, some clinicians
mistakenly perceived this as guideline-inconsistent because they believed that guidelines
impose rigid treatment pathways. Three, the NICE guidelines are a useful source of abstract
information about treatments, but without opportunities to experience recommended
treatments (personally or vicariously) and/or to make personal contact with individual
practitioners clinicians seem unlikely to refer patients to CAM practitioners for NICE-
recommended frontline treatments of acupuncture or manual therapy. Four, a perceived
lack of NHS services, long waiting lists and lack of trusted interdisciplinary networks impedes
referrals for physiotherapy, manual therapy (in particular manipulation), combined
psychological and physical programmes, and acupuncture.
Other studies have described separately: individualised and patient-centred care in
LBP,46-51 clinicians’ understandings of LBP,49;52;53 the clinical relevance of experiential
learning,54 and the challenges of producing and implementing multidisciplinary guidelines to
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help reduce the fragmentation of LBP care.60 Unsatisfactory labels that provide no diagnostic
information have also been discussed for Medically Unexplained Symptoms.61 A meta-
synthesis on GPs’ attitudes towards guidelines in primary care suggests some common
issues, for example perceived tensions between guideline-based care and individualised care
and perceived relevance of guidelines, but the issues we identified around interdisciplinary
networks and structural constraints appear to be far less commonly discussed.62 Reflecting
and extending studies in other conditions,28;32-39 our clinicians varied in how much they were
aware of, were influenced by, and acted in accordance with guidelines.
Interviewing clinicians produced deeper insights than would be possible using
questionnaires. Our findings reflect how clinicians understand their work but, without
ethnographic observations, we were unable to describe clinical practice directly. We
interviewed members of six relevant professions: GPs, physiotherapists, chiropractors,
osteopaths, acupuncturists, and nurses. Only a small number of nurses volunteered to
participate which may reflect that practice nurses are rarely involved in caring for patients
with LBP in primary care, but this small sub-sample should be viewed as a limitation –
interviewing more nurses may have resulted in a more nuanced understanding of their
views. Organisational constraints might be less in other locales where private-sector CAM
practitioners are commissioned to provide NHS services.63
It is well known that merely publishing clinical guidelines and evidence is insufficient
to ensure their implementation.54-56 Our findings suggest specific novel actions that address
key elements of clinical decision-making and could thus increase the relevance of LBP
guidelines for clinical practice. In relation to “knowing the patient”, guidelines could
emphasize the need to attend to patients’ preferences; a clear example might help shift
misperceptions that guidelines are rigid.62;64 In relation to “identifying the problem”,
scientifically developing broad consensus around terminology (e.g. using a Delphi process),
15
clearly communicating the relevance of general terminology to all professional groups
and/or including recent evidence about stratified care65;66 could improve on the inadequate
umbrella term PNS-LBP.67-71 In relation to “knowing the treatment”, medical schools and
professional bodies could do more to follow GMC guidelines and educate clinicians about
the evidence-base and professional regulation of acupuncture, osteopathy, and
chiropractic;72 encouraging local inter-professional networks could facilitate communication
and relationship-building between individual practitioners. These changes would help to
increase GPs’ and nurses’ familiarity with and self-efficacy for referring to CAM practitioners.
To address “organisational constraints”, commissioners need to understand better the need
to purchase recommended treatments (particularly acupuncture, osteopathy, chiropractic
and combined psychological and physical programmes) to enable clinicians to implement
recommended pathways. While purchasing decisions are increasingly challenging given the
broader economic context, commissioners appear to have impeded clinical implementation
of the LBP guidelines in England by failing to fund recommended treatments. This not only
prevents patients receiving recommended treatments but also represents an unfortunate
waste of resources invested in guideline development.73 Developments in NHS
commissioning (e.g. national clinical directors, clinical commissioning groups) provide
opportunities for improved implementation of guidelines. For example, the Any Qualified
Provider policy encourages commissioners to look beyond the NHS for providers.
Implementing recent developments in stratified care which enable sub-grouping of patients
(based on prognosis) for targeted treatments 65;66 might also increase the efficiency and cost-
effectiveness of care.69
Qualitative research on patients’ non-compliance to medical regimes prompted a
radical shift by demonstrating that non-compliance should be re-conceptualised as rational
non-adherence.74 Similarly, qualitative work around clinical decision-making offers deeper
16
insights into the role of guidelines in clinical practice, particularly for more complex
multidisciplinary guidelines. Future studies should consider studying not only clinicians but
also commissioners. Our recommendations could increase the relevance of LBP and possibly
other guidelines for practice, further research is needed to implement and test them.
17
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Table 1. Characteristics of the Purposively Sampled Participants (N=53)
Characteristic Statistic
Category f(%)
Profession
General practitioner (GP) 16 (30%)
Chiropractor 10 (19%)
Physiotherapist 8 (15%)
Acupuncturist 8 (15%)
Osteopath 7 (13%)
Nurse* 4 (8%)
Sector
National Health Service (NHS) 20 (38%)
Private sector 21 (40%)
Both 12 (23%)
Gender
Female 30 (57%)
Male 23 (43%)
Location
Hampshire (Predominantly urban) 29 (55%)
Isle of Wight (Predominantly rural) 5 (9%)
Wiltshire (Predominantly rural) 7 (13%)
Dorset (Predominantly rural) 12 (23%)
Dimension Mean (Range)
Age in years 46 (25 to 67)
Duration of clinical experience in years 19 (2 to 40)
*2 practice nurses, 2 nurse practitioners
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Table 2. Typical focus of clinical decision-making and practice by profession, as expressed by
participants
Focus of clinical decision-making and practice
Profession Identify red flags
Aetiological diagnosis
Refer for treatment
Prescribe pain relief
Deliver tailored treatment
Deliver self-management advice
Deliver CBT
GPs
Nurses
Physiotherapists
CAM Practitioners (osteopaths, chiropractors, acupuncturists)
GP: General Practitioner. CAM: Complementary Alternative Medicine. CBT: Cognitive Behavioural
Therapy.
= Typical focus for participants from this profession
= Atypical focus for participants from this profession
= Explicitly discussed by participants from this profession as beyond their professional scope of
practice
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Table 3. Quotes illustrating perceived helpful and unhelpful aspects of the term “PNS-LBP”
Aspect of the term
“PNS-LBP”
Illustrative quote from study participant
Perceived as helpful
Honesty “Well, it’s as useless as all the other ones we have for back pain, but at
least it says what it is. I’d rather have that, which is understandable, than
something in Latin [...] it doesn’t tell them anything – it just says their
back hurts, which they knew already. So it’s not helpful in that way. It is
honest though.” (Dr SA, male GP, NHS)
Suggests timeframe for
making referrals
“Most episodes would tend to improve at least or even resolve within
about a six week window and if it’s not then... and it’s becoming much
more long term then it’s usually a good idea to involve a physiotherapist
and look at education, look at how it’s affecting work and look at co-
existing depression so it’s people where it’s persisting and interfering with
their quality of life where they would often, you know, benefit from a
referral to physiotherapist or the back pain clinic that we have.” (Dr CA,
male GP, NHS)
Perceived as unhelpful
Unfamiliar and
uninformative for
patients
“I don’t know what you’re talking about so I’m sure the patients wouldn’t.
Non-specific, I mean it’s not really very helpful. They’ve either got muscle
and joint and ligament pain or they’ve got nerve entrapment and that’s
what they want to hear, they don’t want to hear terms like non-specific
back pain, they want to know what it is and what it isn’t.” (Dr AD, male
29
GP, NHS)
Clinically uninformative “We have struggled to create homogenous groups and have ended up
almost as a default setting, ended up with this term ‘persistent non-
specific lower back pain’. In terms of being a clinician that term offers
absolutely zero in terms of helping us with our approach to the
management of that patient. It doesn’t tell us in terms of diagnosis, it
doesn’t tell us a classification or mechanism or indeed anything about that
patient’s disorder and therefore it really is quite unhelpful if we are
looking for a term to help us clinically.” (Mr AN, physiotherapist, NHS and
private practice)
PNS-LBP: Persistent Non-Specific Low Back Pain. GP: General Practitioner. NHS: National Health
Service.
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Table 4. Quotes illustrating subthemes related to “knowing the treatment”
Subtheme Illustrative quote from study participant
Accepting evidence-based
medicine
“I think we've got to be evidence-based, we've got to be able to justify
what we do.” (Ms NE, Physiotherapist, NHS and private practice).
Resisting evidence-based
medicine
“One or two good personal successes tend to be a bigger stick than
evidence-based, I don’t know, maybe. Evidence-based seems to be
reversed every couple of years. They change their minds.” (Dr. AD,
male GP, NHS)
“I think experience counts for quite a lot, listening to colleagues as well
who have experience as well. I suppose reading NICE guidelines, I can’t
remember when they came out, probably influenced me to a minor
degree but more to do with experience with colleagues and experience
of seeing what the outcomes are.” (Dr GE, male GP, NHS)
“Chiropracticing I’ve been doing for 29 years and I know the benefits of
it and to what extent it can be helpful to the patient.” (Mr MI,
chiropractor, Private)
Not knowing about
guideline-recommended
treatments
“I wouldn’t be able to recommend things like chiropractors and
osteopaths, because I’ve never had any training or education on what
they [do], who they are, what they are. How would I recognise, you
know, expertise, or, you know, proper training or anything. I wouldn’t
be able to.” (Ms CO, practice nurse, NHS)
Guidelines as raising
awareness about
“I did feel that the NICE guidelines were really there for the
information of the public and for medical practitioners; perhaps the
31
treatments public might – if they were informed of it – perhaps the public might
choose acupuncture treatment themselves.” (Ms HA, acupuncturist,
private practice)
GP: General Practitioner. NHS: National Health Service.
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Table 5. Quotes illustrating subthemes related to working within organisational constraints
Subtheme Illustrative quote
Valuing accessible high
quality services
“I would always be recommending a physiotherapist in the first instance
because we happen to have a contract with the local provider. The quality
of the care, the timeliness of the service and everything about it is to a
very high standard and to everybody’s satisfaction and there just doesn’t
seem for the average patient a role in terms of an NHS referral to any
other party unless a patient strongly prefers it.” (Dr BA, male GP, NHS)
Disparities between
real-world situation
and guideline-
recommended
pathways
“I think they are a lovely pie in the sky plans and we can’t even get the
stuff for people who are desperately bad. So structured exercises
programmes, 8 – 12 weeks, ha ha, you’ll be lucky if you get 3 sessions out
of the NHS physio[therapist]. I’ve got the guidelines here – they’re
unrealistic with the real world and all the funding issues.” (Dr MO, female
GP, NHS)
Pain clinics as a
gateway to access
(limited) CAM
“If things get very bad then we have access to the pain clinic which is
obviously the specialist anaesthetist, they can sometimes help, they have
access to a variety of treatments we are not able to prescribe, for example,
they can give patients acupuncture so most of my patients are quite
impoverished, they wouldn’t be able to afford to go to see any kind of
complementary practitioner themselves, so I would talk to them about
chiropractors and osteopaths and acupuncturists, but almost always they’ll
say I simply can’t afford it so if we are thinking about something like that it
has to go through the pain clinic for them to get it on the NHS which is a
shame because I think a lot of people do benefit from those sorts of
33
Supplemental Digital Content 1
Table. Summary of LBP Clinical Guidelines.
UK9 USA24 Europe 23;75
Population Persistent non-specific LBP in primary care
Acute Chronic or sub-acute Acute non-specific LBP in primary care 75
Chronic non-specific LBP 23
Recommended treatments: Frontline
Frontline: Patient education, pain-relief medication, and either a structured exercise programme, manual therapy (including spinal manipulation, spinal mobilisation and massage), or acupuncture.
Frontline: Patient education, pain-relief medication.
Frontline: Patient education, pain-relief medication.
Frontline: Patient education, pain-relief medication.
Pain relief medication.
Conservative treatments: cognitive behavioural therapy (CBT), supervised exercise, patient education, multidisciplinary treatment, back schools, manipulation/ mobilisation.
Recommended treatments: Additional
If pain persists: substantial multidisciplinary treatment (100 hours combined physical and cognitive behavioural therapies). If pain persists beyond 1 year, consider referral for an opinion on spinal fusion
Consider adding spinal manipulation.
Consider adding intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioural therapy, progressive relaxation.
Consider adding muscle relaxants, spinal manipulation.
If pain and sick leave persists: multidisciplinary treatment
Invasive treatments: percutaneous electrical nerve stimulation (PENS), neuroreflexotherapy, surgery only in carefully selected chronic cases.
35