Barriers and progress in the treatment of low back pain
© Foster; licensee BioMed Central Ltd. 2011
Received: 9 August 2011
Accepted: 27 September 2011
Published: 27 September 2011
Low back pain is a common and costly condition and for most people is likely to be a recurrent problem throughout their lifetime. The management of patients with low back pain has been positively influenced by the rise in high quality clinical trials and systematic reviews in recent decades, and this body of evidence, synthesized in many clinical practice guidelines, has improved our knowledge about which treatments for low back pain are useful and which are not. For the largest group of patients, those with non-specific low back pain for whom a clear diagnosis cannot be given, the reality is that the treatments we have to offer tend to produce small effects, often only in the short term and none appear to effectively change long-term prognosis. This commentary summarizes the array of treatments currently available, notes the results of recent trials and guidelines and considers alternative approaches that may prove more valuable in achieving better patient outcomes in the future.
Nearly everyone gets low back pain (LBP) at least once in their lifetime making the effective treatment of this common complaint of widespread interest. It is the most common reason for middle-aged people to visit their family doctor  with approximately 6% to 9% of adults consulting for this condition each year [1, 2]. Although many LBP patients stop consulting within three months, 60% to 80% of people still report pain or disability a year later, and up to 40% of those who have taken time off work will have future episodes of work absence [3, 4]. Hence, previous ideas of acute (less than four weeks), sub-acute (four weeks to 12 weeks) and chronic LBP (more than 12 weeks) are gradually being superseded by the view of LBP as a chronic, recurrent condition with an untidy pattern of symptomatic episodes, remissions and recurrences . Dunn and colleagues  proposed four trajectories for LBP patients representing different paths over time; persistent mild, recovering, severe chronic and fluctuating, paths that have been since confirmed in other samples . The societal cost of LBP-related work absence is considerable. Patients with LBP account for more than $90 billion annually in health care expenses in the US  and $9.17 billion in total costs in Australia . In the UK, costs are in the region of 1% to 2% of gross national product  with National Health Service (NHS) costs alone of £251 million annually .
Recent years have seen an exponential increase in research focused on LBP and early criticisms about poor quality studies have largely been addressed by recent trials using rigorous methodology [11–14]. Many practice guidelines [15–17] are now available to help practitioners choose treatments that are safe and effective. A sobering reflection however is that no treatment has large, significant and consistent benefits for patients with non-specific LBP. Despite decades of research and improved quality of clinical trials, the reality is that the treatments we have to offer patients tend to produce small effects, often only in the short term and none appear to change effectively the longer-term prognostic paths or trajectories for patients.
In this commentary I will discuss the variety of current treatment options and recent guideline recommendations, then consider the trends in results of recent high quality trials and the potential explanations for them before suggesting key alternative approaches of potentially more value in achieving better patient outcomes in the future.
Current treatment options and guideline recommendations
There is an almost endless list of treatment options currently available to patients with LBP, each supported by different theories, potential mechanisms, underpinning rationales and research evidence. Some are accompanied by extravagant claims of complete pain relief, often advertised via the internet . Most of these claims and unusual treatment approaches have not proven to be effective when subjected to rigorous and independent evaluation . Treatments include oral medications, topical medications, exercise, manual therapy, traction, acupuncture, transcutaneous electrical nerve stimulation (TENS), spinal cord stimulators, mattresses, orthotics, back supports, biofeedback, spinal injections and surgery. In other words, LBP patients may be offered treatments from the full range of conservative, pharmacological, non-pharmacological, traditional and complementary healthcare interventions as well as invasive interventions.
Given this almost limitless array of options, it is not uncommon for patients with similar LBP signs and symptoms to receive different interventions from healthcare professionals. Key reasons for such variation in practice [20, 21] are firstly, the close commitment of different intervention providers to their respective favorite treatments and secondly, the clinical uncertainty associated with LBP, in terms of diagnosis, prognosis and treatment selection. Evidence for the first reason is provided by studies that show the association between the attitudes and beliefs of practitioners and their clinical behaviors for patients with LBP . As for the second reason, we know that the serious pathologies such as cancer, infection and inflammatory disease account for less than one percent of LBP cases, nerve root problems (associated with radiculopathy or spinal stenosis) are thought to explain no more than 10% to 15% of cases, whereas most LBP (an estimated 85%) is suggested to be 'non-specific', resulting in three diagnostic groups. Given that the term 'non-specific LBP' most likely refers to many LBP problems with different etiologies, ensuring 'the right patient gets the right treatment at the right time' is a particular challenge. While imaging seems a logical way to resolve this dilemma, the use of early magnetic resonance imaging (MRI) scans does not alter patients' outcomes and are actually associated with persistent perceptions of poor health .
More than 2,500 controlled trials of treatments for back and neck pain listed in the Cochrane database, 32 Cochrane systematic reviews of randomized trials, 13 recent national clinical guidelines and two international guidelines from Europe have led to general agreement about best practice for non-specific LBP around the world . This starts with the provision of information about the expected course of the problem and self-care options that patients should try, early and gradual return to normal activities including work, discouragement of bed rest as a treatment, avoidance of routine imaging, use of first line medications (starting with time-contingent acetaminophen and progressing to non-steroidal anti-inflammatory drugs if needed), and the assessment of psychosocial risk factors for chronicity (although the detail of how best to do this varies considerably between available guidelines). The use of passive treatments such as electrotherapy and therapeutic ultrasound is generally discouraged. As LBP persists, best practice recommendations include non-pharmacological therapies with proven benefits; supervised exercise, manual therapy, acupuncture, cognitive behavioral therapy with intensive multidisciplinary treatments reserved for those who do not benefit from these approaches [16, 17, 23]. The content of recent guidelines, irrespective of country, is broadly similar regarding the diagnostic classification (the diagnostic triage outlined above) and the use of diagnostic and therapeutic interventions with some discrepancy around the use of spinal manipulation and some stronger medications .
Why aren't treatments more effective?
There are likely several key explanations, explored in detail elsewhere [19, 24]. Firstly, many of our current treatments are predicated on a healthcare practitioner's specific diagnosis, based on for example imaging findings or the results of subjective and objective examination, yet these approaches to diagnosis correlate poorly with the patient's symptoms , their onward path or trajectory, or their treatment responsiveness. Secondly, patient heterogeneity in clinical trials means that the average treatment effect masks a wide range of individual responses to any specific treatment, including for example, patients who benefit a great deal along with those who benefit little or not at all . Thus a compelling argument for our lack of progress in achieving better treatment results is that we have failed to focus on identifying and addressing the factors that really do influence patients' outcomes . In other words, we have largely failed to match patients with the most appropriate treatment for their individual profile. Identification of clinically relevant subgroups of non-specific LBP patients may be related to causal mechanisms, different prognoses or treatment responsiveness. For example, although psychosocial factors associated with poor prognosis (or yellow flags) have been shown to be important in the development of chronicity and future disability [25, 26] and most guidelines recommend the assessment of these factors, there have been few easy-to-use tools to help clinicians identify these factors in busy clinical practice and limited guidance about appropriate treatment for patients in whom these factors are identified. Although healthcare professionals often feel they can intuitively identify the patients with LBP who have a poor prognosis, actually these patients are often difficult to spot and professionals make inconsistent risk estimations about LBP patients when using intuition alone . More individual and accurate estimates of the prognosis of patients are needed so that we might better target the treatments we offer to those who need them . Several clinical tools exist to aid healthcare professionals in identifying patients either at risk of chronicity or to improve targeting of treatment, summarized in Hill et al. . One of the most widely used is the 24-item Örebro Musculoskeletal Pain Screening Questionnaire which is still rather long for use in busy clinical practice. A recently validated tool to identify risk subgroups of LBP patients is the shorter nine item STarT Back Tool  which has been shown to have similar properties to the Örebro instrument but is easier for patients to complete and professionals to score .
A second compelling explanation for the generally poor outcomes seen in usual practice such as primary care settings  is the limited way in which best evidence recommendations have been translated into everyday clinical practice for patients with LBP. For example, we know that early access to advice and information about self-management and some specific treatments such as exercise, manual therapy, acupuncture and cognitive-behavioral interventions are effective, yet most patients in primary care actually receive symptomatic care through advice related to the current episode and medication alone, neither of which has a clear focus on secondary prevention. Another example is return to work advice, where just under a third of healthcare practitioners continue to recommend staying off work to patients for whom guideline recommendations suggest the opposite . Reasons why adherence to guideline recommendations for work might be less than ideal are unclear, but may be, in part, due to the complex nature of the clinical consultation, in which healthcare professionals such as general practitioners (GPs) want to tailor their decisions according to a patient's individual expectations and demands and thus place higher relative importance on maintaining a good long term relationship with their patient rather than adhering to guideline recommendations. Confronting patients about sickness certification may therefore be seen as a potential threat to the practitioner-patient relationship by some GPs while for others, they may feel they are not best placed to judge whether a LBP patient can return to work safely.
Potentially more effective approaches and future directions
There are at least two avenues that may provide better progress on the road to improving the outcomes of this patient group. One requires a clearer focus on the factors that influence LBP outcome so we can use that information to test different approaches to subgrouping or screening LBP patients for targeted treatment. This is one of the research recommendations in the recent National Institute of Health and Clinical Excellence guidelines for LBP in the UK . There are promising developments in this field [27–33], with one such example involving a change in the focus of treatment from symptomatic relief only to secondary prevention and reducing the risk of future recurrences and chronicity [29, 34]. Patients with poorer physical function and those with psychological obstacles to recovery such as psychological distress, negative feelings about their back pain and increased fear of activity, are more disabled by their pain and are more likely to have a poor outcome . A potentially more effective system would be one in which there is early identification of patients at risk of chronicity and subsequently efforts to prevent such chronicity . Addressing these factors in primary care at an early stage before they become entrenched and more difficult to treat could lead to better long term outcomes. Prognostic assessment tools, in primary care, identifying subgroups of patients at risk of persistent LBP, and who may benefit from interventions that target key physical and/or psychological obstacles to recovery have been developed and validated. One example of this is the STarT Back tool . Specifically designed for primary care settings, the STarT Back tool is a subgrouping instrument that classifies patients into three categories for targeted treatment, based on the presence of modifiable risk factors for poor outcome. A randomized controlled trial (the STarT Back trial) is testing whether subgrouping for targeted treatment is better than best current care (provided by physiotherapists) of non-targeted treatment . This potentially more effective treatment strategy is an example of a move towards stratified healthcare and away from the one-size-fits-all approach, improving the odds of getting the right patient to the right treatment at the right time.
Perhaps a less exciting but no less challenging approach to improving outcomes for patients with LBP is to invest much more effort in translating best practice recommendations from high quality research into everyday clinical practice. Such approaches are likely to need to include not only patients as targets for the intervention but also the healthcare practitioners and organizational processes involved in their care. Several studies have attempted to change healthcare practitioner behavior for LBP patients [36–44] and overall highlight the considerable challenges and generally small effects of implementation efforts to date. Targeting the general public through mass media campaigns about LBP has shown promise [45–47] and the benefit of this type of approach is the way in which the intervention also targets healthcare practitioners. Finding better incentives for practitioners to adopt best practice and working out how public policy can help are both likely to be useful. The cost burden of LBP to society means that research that more carefully develops and tests ways to better support the translation of best practice into everyday clinical practice is a clear priority.
Despite the plethora of treatments for LBP patients, and the production of multiple guidelines for practice, getting the right patient to the right treatment at the right time is still a considerable challenge. Findings from epidemiological studies and recent high quality trials underline the need to consider seriously the following two avenues of progress. Firstly, a move away from a one-size-fits-all approach to LBP and towards greater subgrouping for targeted treatment in LBP, and secondly, more considerable effort to support the translation of best practice and provision of treatments with clear evidence of effectiveness into clinical reality for patients.
- Dunn KM, Croft PR: Classification of low back pain in primary care: using "bothersomeness" to identify the most severe cases. Spine. 2005, 30: 1887-1892. 10.1097/01.brs.0000173900.46863.02.View ArticlePubMedGoogle Scholar
- Jordan KP, Kadam UT, Hayward R, Porcheret M, Young C, Croft P: Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study. BMC Musculoskelet Disord. 2010, 11: 144-10.1186/1471-2474-11-144.View ArticlePubMedPubMed CentralGoogle Scholar
- Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ: The outcome of low back pain in general practice: a prospective study. BMJ. 1998, 316: 1356-1359.View ArticlePubMedPubMed CentralGoogle Scholar
- Hestbaek L, Leboeuf YC, Manniche C: Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J. 2003, 12: 149-165.PubMedPubMed CentralGoogle Scholar
- Dunn KM, Jordan K, Croft PR: Characterising the course of low back pain: a latent class analysis. Am J Epidemiol. 2006, 163: 754-761. 10.1093/aje/kwj100.View ArticlePubMedGoogle Scholar
- Tamcan O, Mannion AF, Eisenring C, Horisberger B, Elfering A, Müller U: The course of chronic and recurrent low back pain in the general population. Pain. 2010, 150: 451-457. 10.1016/j.pain.2010.05.019.View ArticlePubMedGoogle Scholar
- Luo X, Pietrobon R, Sun SX, Liu GG, Hey L: Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine. 2004, 29: 79-86. 10.1097/01.BRS.0000105527.13866.0F.View ArticlePubMedGoogle Scholar
- Walker BF, Muller R, Grant WD: Low back pain in Australian adults: the economic burden. Asia Pac J Public Health. 2003, 15 (2): 79-87. 10.1177/101053950301500202.View ArticlePubMedGoogle Scholar
- Norlund AI, Waddell G: Cost of back pain in some OECD countries. Neck and back pain: the scientific evidence of causes, diagnosis and treatment. Edited by: Nachemson AL, Jonsson E. 2000, Philadelphia: Lippincott, Williams & Wilkins, 421-425. 1Google Scholar
- Maniadakis N, Gray A: The economic burden of back pain in the UK. Pain. 2000, 84: 95-103. 10.1016/S0304-3959(99)00187-6.View ArticlePubMedGoogle Scholar
- UKBEAM team: United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: Effectiveness of physical treatments for back pain in primary care. BMJ. 2004, 329: 1377-1385.View ArticleGoogle Scholar
- Hay EM, Mullis R, Lewis M, Vohora K, Main CJ, Watson P, Dziedzic KS, Sim J, Minns Lowe C, Croft PR: Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice. Lancet. 2005, 365: 2024-2030. 10.1016/S0140-6736(05)66696-2.View ArticlePubMedGoogle Scholar
- Lamb SE, Hansen Z, Lall R, Castelnuovo E, Withers EJ, Nichols V, Potter R, Underwood MR, Back Skills Training Trial investigators: Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis. Lancet. 2010, 375: 916-923. 10.1016/S0140-6736(09)62164-4.View ArticlePubMedGoogle Scholar
- Brox JI, Nygaard ØP, Holm I, Keller A, Ingebrigtsen T, Reikerås O: Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheumat Dis. 2010, 69: 1643-1648. 10.1136/ard.2009.108902.View ArticlePubMedPubMed CentralGoogle Scholar
- Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G: COST B13 European guidelines for the management of chronic non-specific low back pain. Eur Spine J. 2006, 15: S192-S300. 10.1007/s00586-006-1072-1.View ArticlePubMedPubMed CentralGoogle Scholar
- Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK: 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: 478-491.View ArticlePubMedGoogle Scholar
- Savigny P, Kuntze S, Watson P, Underwood M, Ritchie G, Cotterell M, Hill D, Browne N, Buchanan E, Coffey P, Dixon P, Drummond C, Flanagan M, Griffiths M, Halliday-Bell J, Hettinga D, Vogel S, Walsh D: Low Back Pain: Early management of persistent non-specific low back pain. 2009, National Collaborating Centre for Primary Care and Royal College of General Practitioners, LondonGoogle Scholar
- Butler L, Foster NE: Back pain online: a cross-sectional survey of the quality of web-based information on low back pain. Spine. 2003, 28: 395-401.PubMedGoogle Scholar
- Pransky G, Buchbinder R, Hayden J: Contemporary low back pain research - and implications for practice. Best Pract Res Clin Rheumatol. 2010, 24: 291-298. 10.1016/j.berh.2010.01.001.View ArticlePubMedGoogle Scholar
- Foster NE, Thompson K, Baxter GD, Allen JM: Management of non-specific low back pain by physiotherapists in Britain and Ireland: a descriptive questionnaire of current clinical practice. Spine. 1999, 24: 1332-1342. 10.1097/00007632-199907010-00011.View ArticlePubMedGoogle Scholar
- Bishop A, Foster NE, Thomas E, Hay EM: How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health practitioners? A survey of UK general practitioners and physiotherapists. Pain. 2008, 135: 187-195. 10.1016/j.pain.2007.11.010.View ArticlePubMedPubMed CentralGoogle Scholar
- Ash LM, Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN: Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008, 29: 1098-1103. 10.3174/ajnr.A0999.View ArticlePubMedGoogle Scholar
- Koes BW, van Tulder M, Lin CWC, Macedo LG, McAuley J, Maher C: An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010, 19: 2075-2094. 10.1007/s00586-010-1502-y.View ArticlePubMedPubMed CentralGoogle Scholar
- Foster NE, Dziedzic KS, van der Windt DA, Fritz JM, Hay EM: Research priorities for non-pharmacological therapies for common musculoskeletal problems: nationally and internationally agreed recommendations. BMC Musculoskelet Disord. 2009, 10: 3-10.1186/1471-2474-10-3.View ArticlePubMedPubMed CentralGoogle Scholar
- Foster NE, Bishop A, Thomas E, Main C, Horne R, Weinman J, Hay E: Illness perceptions of low back pain patients in primary care: what are they, do they change and are they associated with outcome?. Pain. 2008, 136: 177-187. 10.1016/j.pain.2007.12.007.View ArticlePubMedGoogle Scholar
- Grotle M, Foster NE, Dunn KM, Croft P: Are prognostic indicators for poor outcome different for acute and chronic low back pain consulters in primary care?. Pain. 2010, 151: 790-797. 10.1016/j.pain.2010.09.014.View ArticlePubMedPubMed CentralGoogle Scholar
- Hill JC, Vohora K, Dunn KM, Main CJ, Hay EM: Comparing the STarT back screening tool's subgroup allocation of individual patients with that of independent clinical experts. Clin J Pain. 2010, 26: 783-787. 10.1097/AJP.0b013e3181f18aac.View ArticlePubMedGoogle Scholar
- Hill JC, Dunn KM, Main CJ, Hay EM: Subgrouping low back pain: a comparison of the STarT Back Tool with the Orebro Musculoskeletal Pain Screening Questionnaire. Eur J Pain. 2010, 14: 83-89. 10.1016/j.ejpain.2009.01.003.View ArticlePubMedPubMed CentralGoogle Scholar
- Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, Hay EM: A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. 2008, 59: 632-641. 10.1002/art.23563.View ArticlePubMedGoogle Scholar
- Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE: Identifying subgroups of patients with acute/subacute "nonspecific" low back pain: results of a randomized clinical trial. Spine. 2006, 31: 623-631. 10.1097/01.brs.0000202807.72292.a8.View ArticlePubMedGoogle Scholar
- Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A: A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004, 141: 920-928.View ArticlePubMedGoogle Scholar
- Heymans MW, Anema JR, van Buuren S, Knol DL, van Mechelen W, de Vet HC: Return to work in a cohort of low back pain patients: development and validation of a clinical prediction rule. J Occup Rehabil. 2009, 19: 155-165. 10.1007/s10926-009-9166-3.View ArticlePubMedGoogle Scholar
- Dionne CE, Bourbonnais R, Frémont P, Rossignol M, Stock SR, Larocque I: A clinical return-to-work rule for patients with back pain. CMAJ. 2005, 172: 1559-1567. 10.1503/cmaj.1041159.View ArticlePubMedPubMed CentralGoogle Scholar
- Hay EM, Dunn KM, Hill JC, Lewis M, Mason EE, Konstantinou K, Sowden G, Somerville S, Vohora K, Whitehurst D, Main CJ: A randomised clinical trial of subgrouping and targeted treatment for low back pain compared with best current care. The STarT Back Trial Study Protocol. BMC Musculoskelet Dis. 2008, 9: 58-10.1186/1471-2474-9-58.View ArticleGoogle Scholar
- Koes BW, van Tulder MW, Thomas S: Diagnosis and treatment of low back pain. BMJ. 2006, 332: 1430-1434. 10.1136/bmj.332.7555.1430.View ArticlePubMedPubMed CentralGoogle Scholar
- Bishop PB, Wing PC: Knowledge transfer in family physicians managing patients with acute low back pain: a prospective randomised control trial. Spine J. 2006, 6: 282-288. 10.1016/j.spinee.2005.10.008.View ArticlePubMedGoogle Scholar
- Ammendolia C, Hogg-Johnson S, Pennick V, Glazier R, Bombardier C: Implementing evidence-based guidelines for radiography in acute low back pain: a pilot study in a chiropractic community. J Manip Physiol Ther. 2004, 27: 170-179. 10.1016/j.jmpt.2003.12.021.View ArticleGoogle Scholar
- Dey P, Simpson CW, Collins SI, Hodgson G, Dowrick CF, Simison AJ, Rose MJ: Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial. BJGP. 2004, 54: 33-37.PubMedPubMed CentralGoogle Scholar
- Enges AJ, Wensing M, van Tulder MW, Timmermanns A, Oostendorp RA, Koes BW, Grol R: Implementation of the Dutch low back pain guideline for general practitioners: a cluster randomised controlled trial. Spine. 2005, 30: 559-600. 10.1097/01.brs.0000155406.79479.3a.View ArticleGoogle Scholar
- Schectman JM, Schroth WS, Verme D, Voss JD: Randomised controlled trial of education and feedback for implementation of guidelines for acute low back pain. J Gen Intern Med. 2003, 18: 773-780. 10.1046/j.1525-1497.2003.10205.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Becker A, Leonhardt C, Kochen MM, Keller S, Wegscheider K, Baum E, Donner-Banzhoff N, Pfingsten M, Hildebrandt J, Basler HD, Chenot JF: Effects of two guideline implementation strategies on patient outcomes in primary care: a cluster randomized controlled trial. Spine. 2008, 33: 473-480. 10.1097/BRS.0b013e3181657e0d.View ArticlePubMedGoogle Scholar
- Bekkering GE, van Tulder MW, Hendriks EJM, Koopmanschap MA, Knol DL, Bouter LM, Oostendorp RAB: 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: 544-555.PubMedGoogle Scholar
- Evans D, Breen A, Pincus T, Sim J, Underwood M, Vogel S, Foster NE: The effectiveness of a posted information package on the beliefs and behaviour of musculoskeletal practitioners: the UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) randomised trial. Spine. 2010, 35: 858-866. 10.1097/BRS.0b013e3181d4e04b.View ArticlePubMedGoogle Scholar
- Foster NE, Mullis R, Young J, Doyle C, Lewis M, Whitehurst D, Hay EM, IMPaCT Back Study team: IMPaCTBack study protocol. Implementation of subgrouping for targeted treatment systems for low back pain patients in primary care: a prospective population-based sequential comparison. BMC Musculoskelet Disord. 2010, 11: 186-10.1186/1471-2474-11-186.View ArticlePubMedPubMed CentralGoogle Scholar
- Buchbinder R, Jolley D, Wyatt M: Population based intervention to change back pain beliefs and disability: three part evaluation. BMJ. 2001, 322: 1516-1520. 10.1136/bmj.322.7301.1516.View ArticlePubMedPubMed CentralGoogle Scholar
- Buchbinder R, Jolley D, Wyatt M: Volvo Award Winner in Clinical Studies: Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice. Spine. 2001, 26: 2535-2542. 10.1097/00007632-200112010-00005.View ArticlePubMedGoogle Scholar
- Buchinder R, Jolley D: Population-based intervention to change back pain beliefs: a three-year follow up study. BMJ. 2004, 328: 321-10.1136/bmj.328.7435.321.View ArticleGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://0-www.biomedcentral.com.brum.beds.ac.uk/1741-7015/9/108/prepub
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