Why less is more when treating low back pain in the emergency department

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

When you mention lower back pain, everyone has a story. If you’re an emergency physician or emergency room nurse, there’s a good chance you’ve treated a patient with back pain, a condition that ranks among the top five most frequent emergency room visits.¹ There is also a high chance that you know a family member, friend or colleague who has suffered from lower back pain.

The release in September of Australia’s first clinical standard for low back pain, which assists in the assessment and early management of episodes of acute low back pain, has been applauded across the healthcare and consumer sectors. The standard is seen as a significant step forward in addressing this common but often distressing and debilitating condition.

Severity of lower back pain

In Australia, low back pain is the leading cause of disability and the leading cause of 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 disease places a significant burden on emergency departments, accounting for up to 2% of all visits and requiring an average length of stay of 4 to 5 hours.⁶

Over time, there has been a marked shift in the recommended treatment for low back pain. The use of imaging, bed rest, pain medication, and surgery are now recognized as limited treatments for most people with this condition. Current evidence suggests that patient education and advice, as well as promotion of self-management and physical activity, are more effective.⁷

Although we now have a good understanding of how to treat low back pain, many people still do not receive recommended care or receive care that is not optimal.^7,8 A recent systematic review of 195,000 patients in seven countries, including Australia, found that approximately one in three low back pain patients presenting to the emergency department received a referral for imaging, and up to 60% were prescribed opioids.⁹

Roadmap for clinical care

The Australian Commission on Care Safety and Quality (Commission) has developed a standard of clinical care for low back pain with a focus on early management in emergency departments and primary care. The standard provides practitioners with a “road map” to help patients manage episodes of low back pain and reduce the likelihood of ongoing problems.

The standard includes eight evidence-based quality statements that describe what best care practices should include (see Box 1). These include preserving imaging for serious underlying pathology and judicious use of pain medication.

The Commission has developed a “Quick Guide for Emergency Departments” that provides an overview of the care described in the Clinical Standards of Care, with key actions and communication tips for emergency physicians (see Figure 1).

Use pain medication wisely

It should be noted that there is a shift in messaging around the role of pain medication in the standard. Clinicians are encouraged to advise patients that pain medication should be used to support activity, not to relieve pain.

The standard recommends complete avoidance of anticonvulsants, benzodiazepines, and antidepressants and advises the use of opioid analgesics only in carefully selected patients in minimal doses for the shortest possible period.

In the emergency department, simple analgesics and non-pharmacological methods of treatment should be used whenever possible. If opioids are prescribed, the duration of therapy should be explained to the patient and included in the discharge to avoid prolonged use.

Reserve imaging for serious underlying pathology

Concerns have been raised for some time about the possible overuse of lumbar spine imaging. The standard states 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 advice for clinicians on how to explain and reassure patients. Once a potentially serious cause has been ruled out, it is important to discuss imaging expectations and the limited role of imaging in the diagnosis of 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 aging.

A consistent approach

A study of routine low back pain care found that there are many opportunities to provide better care for patients.⁹ Consistent communication and education of all clinicians involved in a patient’s care is key to dispelling myths and supporting shared decision making.

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

The standard helps practitioners and healthcare organizations provide effective care for patients with low back pain, who may receive treatment from different healthcare settings and often receive conflicting advice. People with back pain can seek help from emergency physicians, general practitioners, and allied health professionals such as physical therapists and chiropractors.

With a consistent approach and encouraging messages, 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 the resources at: safetyandquality.gov.au/lowbackpain-ccs

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

*Assistant Professor Liz Marles is the Clinical Director of the Australian Commission on Healthcare Safety and Quality and led the development of the standard for the clinical management of low back pain and chaired the topic working group. She provides strategic leadership for work related to primary and community care. A/Prof Marles is a General Practitioner at the Hornsby-Brooklyn GP Unit, with a special interest in chronic illness, mental health and Aboriginal health, and a strong focus on holistic and preventative care.

Links

^{1. Australian Institute of Health and Welfare. Australian Hospital Statistics: Care in Emergency Departments, 2020–2021. Table 4.9: 20 most common primary diagnoses for emergency department visits. AIHW; 2022 year.}

^{2. Schofield DJ and others. Labor force participation and the impact of back problems on poverty in Australia. Spine 2012.}

^{3. Schofield DJ and others. Productive years of life lost due to chronic disease in Australians aged 45–64, 2010–2030. Med J Aust. 2015 year.}

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

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

^{6. Lovegrove, MT and others. Analysis of 22,655 back pain presentations to a Perth emergency department over five years, International Journal of Emergency Medicine, 2011.}

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

^{8. Buchbinder R and others. Low back pain: a call to action. Lancet 2018.}

^{9. Camper SJ and others. What is the usual treatment for lower back pain? A systematic review of care provided to patients with low back pain in family practice and emergency departments. Pain 2020.}

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