“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:

F.L.Bishop@southampton.ac.uk.

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.

3

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.

4

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

5

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

6

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.

8

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.

11

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)

13

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

14

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

References

1. Miles A, Loughlin M. Models in the balance: evidence-based medicine versus

evidence-informed individualized care. J Eval Clin Pract 2011;17:531-6.

2. Walsh K, Cruddas M, Coggon D. Low back pain in eight areas of Britain. J Epidemiol

Community Health 1993;46:227-30.

3. Breivik H, Collett B, Ventafridda V et al. Survey of chronic pain in Europe: Prevalence,

impact on daily life, and treatment. Eur J Pain 2006;10:287-333.

4. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain

2000;84:95-103.

5. Hoy D, Bain C, Williams G et al. A systematic review of the global prevalence of low

back pain. Arthritis & Rheumatism 2012;64:2028-37.

6. Murray CJL, Vos T, Lozano R et al. Disability-adjusted life years (DALYs) for 291

diseases and injuries in 21 regions, 19902010: a systematic analysis for the Global

Burden of Disease Study 2010. The Lancet 2012;380:2197-223.

7. Murray CJ, Richards MA, Newton JN et al. UK health performance: findings of the

Global Burden of Disease Study 2010. The Lancet 2013;381:997-1020.

8. Savigny P, Watson P, Underwood M et al. Early management of persistent non-

specific low back pain: summary of NICE guidance. BMJ 2009;338:b1805.

9. Savigny P, Kuntze S, Watson P et al. Low back pain. Early management of persistent

non-specific low back pain. NICE clinical guideline 88, www.nice.org.uk/CG88. 2009.

18

London, National Collaborating Centre for Primary Care and Royal College of General

Practitioners.

10. Ola PO. The right stitch at the right time saves more than nine! Rapid response to

BMJ 2009;338:b2115. BMJ

2009;http://www.bmj.com/rapid-response/2011/11/02/right-stitch-right-time-

saves-more-nine.

11. Colquhoun D. A "landmark" indeed. Rapid response to BMJ 2009;338:b2115. BMJ

2009;http://www.bmj.com/rapid-response/2011/11/02/landmark-indeed.

12. Basler MH. The NICE guideline - the real issues. Rapid response to BMJ

2009;338:b2115. BMJ 2009;http://www.bmj.com/rapid-response/2011/11/02/nice-

guideline-real-issues.

13. Ward SP. Re: NICE guidelines for the early management of persistent low back pain.

Rapid response to BMJ 2009;338:b2115. BMJ 2009;http://www.bmj.com/rapid-

response/2011/11/02/re-nice-guidelines-early-management-persistent-low-back-

pain.

14. Vagg M. NICE Misguidance. Rapid response to BMJ 2009;338:b2115. BMJ

2009;http://www.bmj.com/rapid-response/2011/11/02/nice-misguidance.

15. Munglani R. NICE guideline on low back pain are flawed. Rapid response to BMJ

2009;338:b2115. BMJ 2009;http://www.bmj.com/rapid-response/2011/11/02/nice-

guideline-low-back-pain-are-flawed.

16. Bartley R. Wishful thinking? Rapid response to BMJ 2009;338:b2115. BMJ

2009;http://www.bmj.com/rapid-response/2011/11/02/wishful-thinking-0.

19

17. Brien S, Howells E, Leydon GM et al. Why GPs refer patients to complementary

medicine via the NHS: a qualitative exploration. Prim Health Care Res Dev

2008;9:205-15.

18. Maha N, Shaw A. Academic doctors' views of complementary and alternative

medicine (CAM) and its role within the NHS: an exploratory qualitative study. BMC

Complement Altern Med 2007;7:17.

19. Breen A, Carrington M, Collier R et al. Communication between general and

manipulative practitioners: A survey. Complement Ther Med 2000;8:8-14.

20. Perry R, Dowrick C, Ernst E. Complementary medicine and general practice in an

urban setting: a decade on. Prim Health Care Res Dev 2013;FirstView Article:1-6.

21. Ernst E, Harkness E. Spinal manipulation; A systematic review of sham-controlled,

double-blind, randomized clinical trials. J Pain Symptom Manage 2001;22:879-89.

22. Colquhoun D, Novella SP. Acupuncture is theatrical placebo. Anesth Analg 2013;116.

23. Airaksinen O, Brox J, Cedraschi C et al. Chapter 4 European guidelines for the

management of chronic nonspecific low back pain. Eur Spine J 2006;15:s192-s300.

24. Chou R, Qaseem A, Snow V et al. Diagnosis and treatment of low back pain: A joint

clinical practice guideline from the American College of Physicians and the American

Pain Society. Ann Intern Med 2007;147:478-91.

25. Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the

assessment and management of low back pain from recent clinical practice

guidelines. The Spine Journal 2010;10:514-29.

20

26. Fritz JM, Cleland JA, Brennan GP. Does adherence to the guideline recommendation

for active treatments improve the quality of care for patients with acute low back

pain delivered by physical therapists? Med Care 2007;45.

27. Rutten GM, Degen S, Hendriks EJ et al. Adherence to clinical practice guidelines for

low back pain in physical therapy: Do patients benefit? Phys Ther 2010;90:1111-22.

28. Rozenberg S, Allaert FA, Savarieau B et al. Compliance among general practitioners

in France with recommendations not to prescribe bed rest for acute low back pain.

Joint Bone Spine 2004;71:56-9.

29. Bekkering GE, van Tulder MW, Hendriks EJM et al. Implementation of clinical

guidelines on physical therapy for patients with low back pain: randomized trial

comparing patient outcomes after a standard and active implementation strategy.

Phys Ther 2005;85:544-55.

30. McGuirk B, King W, Govind J et al. Safety, efficacy, and cost effectiveness of

evidence-based guidelines for the management of acute low back pain in primary

care. Spine 2001;26:2615-22.

31. Rossignol M, Abenhaim L, Séguin P et al. Coordination of primary health care for

back pain: A randomized controlled trial. Spine 2000;25:251-8.

32. González-Urzelai V, Palacio-Elua L, López-de-Munain J. Routine primary care

management of acute low back pain: adherence to clinical guidelines. Eur Spine J

2003;12:589-94.

21

33. Swinkels ICS, van den Ende CHM, van den Bosch W et al. Physiotherapy

management of low back pain: does practice match the Dutch guidelines? Australian

Journal of Physiotherapy 2005;51:35-41.

34. Schers H, Braspenning J, Drijver R et al. Low back pain in general practice: reported

management and reasons for not adhering to the guidelines in the Netherlands. Br J

Gen Pract 2000;50:640-4.

35. Ammendolia C, Taylor JAM, Pennick V et al. Adherence to radiography guidelines for

low back pain: A survey of chiropractic schools worldwide. J Manipulative Physiol

Ther 2008;31:412-8.

36. Coudeyre E, Rannou F, Tubach F et al. General practitioners' fear-avoidance beliefs

influence their management of patients with low back pain. Pain 2006;124:330-7.

37. Corbett M, Foster N, Ong BN. GP attitudes and self-reported behaviour in primary

care consultations for low back pain. Fam Pract 2009;26:359-64.

38. Licciardone J. The epidemiology and medical management of low back pain during

ambulatory medical care visits in the United States. Osteopathic Medicine and

Primary Care 2008;2:11-doi: 10.1186/1750-4732-2-11.

39. Bishop PB, Wing PC. Compliance with clinical practice guidelines in family physicians

managing worker's compensation board patients with acute lower back pain. The

Spine Journal 2003;3:442-50.

40. Evans DW, Breen AC, Pincus T et al. The effectiveness of a posted information

package on the beliefs and behavior of musculoskeletal practitioners: the UK

22

Chiropractors, Osteopaths, and Musculoskeletal Physiotherapists Low Back Pain

ManagemENT (COMPLeMENT) randomized trial. Spine 2010;35:858-66.

41. Somerville S, Hay E, Lewis M et al. Content and outcome of usual primary care for

back pain: a systematic review. Br J Gen Pract 2008;58:790-7.

42. Di Iorio D, Henley E, Doughty A. A survey of primary care physician practice patterns

and adherence to acute low back problem guidelines. Arch Fam Med 2000;9:1015-

21.

43. Cabana MD, Rand CS, Powe NR et al. Why don't physicians follow clinical practice

guidelines? A framework for improvement. JAMA 1999;282:1458-65.

44. Grol R, Dalhuijsen J, Thomas S et al. Attributes of clinical guidelines that influence

use of guidelines in general practice: observational study. BMJ 1998;317.

45. Michie S, Johnston M. Changing clinical behaviour by making guidelines specific. BMJ

2004;328.

46. Breen A, Austin H, Campion-Smith C et al. "You feel so hopeless": A qualitative study

of GP management of acute back pain. Eur J Pain 2007;11:21-9.

47. Macfarlane GJ, Beasley M, Jones EA et al. The prevalence and management of low

back pain across adulthood: Results from a population-based cross-sectional study

(the MUSICIAN study). Pain 2012;153:27-32.

48. Schers H, Wensing M, Huijsmans Z et al. Implementation barriers for general

practice guidelines on low back pain: A qualitative study. Spine 2001;26:E348-E353.

23

49. Werner EL, Côté P, Fullen BM et al. Physicians' determinants for sick-listing LBP

patients: A systematic review. Clin J Pain 2012;28.

50. Chew-Graham C, May C. Chronic low back pain in general practice: the challenge of

the consultation. Fam Pract 1999;16:46-9.

51. Jeffrey J, Foster N. A qualitative investigation of physical therapists' experiences and

feelings of managing patients with nonspecific low back pain. Phys Ther

2012;92:266-78.

52. Pincus T, Foster NE, Vogel S et al. Attitudes to back pain amongst musculoskeletal

practitioners: A comparison of professional groups and practice settings using the

ABS-mp. Man Ther 2007;12:167-75.

53. Bishop A, Foster NE, Thomas E et al. How does the self-reported clinical

management of patients with low back pain relate to the attitudes and beliefs of

health care practitioners? A survey of UK general practitioners and physiotherapists.

Pain 2008;135:187-95.

54. John G, Andrée lM. Evidence based guidelines or collectively constructed

"mindlines?"Ethnographic study of knowledge management in primary care. BMJ

2004;329:1013.

55. Berwick DMM. Disseminating innovations in health care. JAMA 2003;289:1969-75.

56. Grol R. Successes and failures in the implementation of evidence-based guidelines

for clinical practice. Med Care 2001;39:II-46-II-54.

57. Joffe H, Yardley L. Content and thematic analysis. In: Marks DF, ed. Research

methods for clinical and health psychology. London: Sage, 2004:56-68.

24

58. Glaser BG, Strauss A. The discovery of grounded theory. In: Glaser BG, Strauss A, eds.

The discovery of grounded theory. London: Weidenfeld and Nicolson, 1967:1-18.

59. NVivo qualitative data analysis software, Version 9.QSR International Pty Ltd, 2010.

60. Breen AC, van Tulder MW, Koes BW et al. Mono-disciplinary or multidisciplinary

back pain guidelines? How can we achieve a common message in primary care? Eur

Spine J 2006;15:641-7.

61. Stone J, Wojcik W, Durrance D et al. What should we say to patients with symptoms

unexplained by disease? The "number needed to offend". BMJ 2002;325.

62. Carlsen B, Glenton C, Pope C. Thou shalt versus thou shalt not: a meta-synthesis of

GPs' attitudes to clinical practice guidelines. Br J Gen Pract 2007;57:971-8.

63. Gurden M, Morelli M, Sharp G et al. Evaluation of a general practitioner referral

service for manual treatment of back and neck pain. Prim Health Care Res Dev

2012;13:204-10.

64. Montori VM, Brito JP, Murad MH. The optimal practice of evidence-based medicine.

incorporating patient preferences in practice guidelines. JAMA 2014;310:2503-4.

65. Foster NE, Mullis R, Hill JC et al. Effect of stratified care for low back pain in family

practice (IMPaCT Back): A prospective population-based sequential comparison. Ann

Fam Med 2014;12:102-11.

66. Hill JC, Whitehurst DG, Lewis M et al. Comparison of stratified primary care

management for low back pain with current best practice (STarT Back): a

randomised controlled trial. The Lancet 2011;378:1560-71.

25

67. Waddell G. Subgroups within "nonspecific" low back pain. J Rheumatol 2005;32:395-

6.

68. Bogduk N. What's in a name? The labelling of back pain. Med J Aust 2000;173:400-1.

69. Costa LdaC, Koes BW, Pransky G et al. Primary care research priorities in low back

pain: an update. Spine 2013;38:148-56.

70. Barker K, Reid M, Lowe C. Divided by a lack of common language? - a qualitative

study exploring the use of language by health professionals treating back pain. BMC

Musculoskelet Disord 2009;10:123.

71. Kent P, Keating J. Do primary-care clinicians think that nonspecific low back pain is

one condition? Spine 2004;29:1022-31.

72. Catto G, Cork N, Williams G. Should medical students be taught alternative

medicine? BMJ 2014;348:g2417.

73. Pronovost PJ. Enhancing physicians' use of clinical guidelines. JAMA

2013;doi:10.1001/jama.2013.281334:E1-E2.

74. Donovan JL, Blake DR. Patient non-compliance: Deviance or reasoned decision

making? Soc Sci Med 1992;34:507-13.

75. van Tulder M, Becker A, Bekkering T et al. Chapter 3 European guidelines for the

management of acute nonspecific low back pain in primary care. Eur Spine J

2006;15:s169-s191.

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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

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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

treatments.” (Dr TA, female GP, NHS)

GP: General Practitioner. NHS: National Health Service.

34

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