Back pain is usually classified as specific or non-specific. Specific back pain is caused by a pathophysiological mechanism, such as disc prolapse, infection, inflammatory arthropathy, tumour, osteoporosis or fracture. Non-specific back pain is defined as symptoms of unknown origin or without identifiable pathology. The majority of patients presenting with back trouble have non-specific low back pain. Additionally, back pain is classified according to the duration of symptoms: as acute when it persists for less than 6 weeks, subacute between 6 and 12 weeks, and chronic for more than 12 weeks.
Back pain, and particularly low back pain, is a common reason for physician visits in all Western industrialized countries. It is also very costly, leading to high direct health care costs and indirect costs related to days lost from work, work force compensation and early retirement.
There is a large list of treatment approaches available, promoted as solutions to this wide-spread problem. However, patients receiving these treatments and managed by health care providers from different specialities appear to have similar outcomes, although the cost of care often differs substantially both between and within specialities. It has also been observed that a small number of patients with chronic back pain consume a large amount of the resources.
It is a generally accepted principle in most fields of health care that a treatment should not be offered to the public until there is sufficient evidence supporting its effectiveness and safety. Because of the high prevalence of back pain, a lot of studies have been performed evaluating the efficacy and safety of the various procedures. But because patients with back pain frequently present when their symptoms are at their worst, regression to the mean is often significant and can lead to inflated estimates of beneficial effects. Therefore, the evaluation of the efficacy of therapies for the management of back pain should be based on randomized controlled trials (RCTs), if possible with adequate blinding.
Meanwhile, the results of a large number of RCTs have become available, and many systematic reviews summarize the evidence from these RCTs. The Cochrane Back Review Group has developed guidance on systematic literature reviews to decrease the potential for bias, improve the quality of reviews, enhance consistency among reviewers and facilitate comparison across reviews.
Systematic reviews provided the scientific evidence base for clinical guidelines. A number of national and international guidelines for the management of non-specific back pain, specifically low back pain, have been published. Some of them, including the recent Austrian guidelines, are presented in this HTA-report. Despite differences in health care systems and cultures, most diagnostic and therapeutic recommendations between guidelines are similar. All guidelines recommend an active approach.
The richer evidence has greatly improved the knowledge of what does and does not work for back pain, and there is widespread agreement and some evidence that adherence to evidence-based practice will help improve back pain patient outcomes and reduce arbitrary variations in care. Despite these advances, the best available evidence often does not inform everyday clinical decisions.
In fact, many clinicians do not follow or have knowledge of even basic guideline recommendations. Research indicates that passive methods of guidelines dissemination, such as simply distributing the guidelines, are unlikely to change physician practice. Active strategies combining multiple approaches are likely to be more effective, although additional research on effective implementation techniques is needed.
There are a variety of barriers to guideline adherence including lack of outcome expectancy, the inertia of previous practice, concern over malpractice liability, patient desires, and others. Further, management according to evidence-based guidelines is not necessarily economically attractive.
Changing clinical practice and the behaviour of health professionals or patients is very complex and guidelines alone are not enough to change. This HTA-report summarizes possible strategies of how to improve the care for patients with non-specific back pain in Austria and overcome structural barriers.