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Article Series By Dr. Shawn Thistle Nov. 2011


INTRODUCTION - Our Opportunity to Lead the Way

My goal in writing this article series was not to discourage, but rather to inspire healthcare providers like you to seize the opportunity to excel and lead the way in caring for LBP for coming generations. We have the knowledge base now to have a meaningful and effective impact on patients with LBP. We simply must act.

I think Dr. Richard Deyo, a well-respected and well-published clinician, summarized it best (9): “…patients and the public need more unbiased information about back pain management, so expectations are congruent with clinical realities. Too often, product marketing, media reporting, and our own wishful thinking seem to promise definitive answers and a pain-free life. Both doctors and patients need expectations that are more realistic, more accurate language, and clear-eyed sharing of management decisions. Somehow, we need to get better congruence between what we say and what we do, channelling money to where our mouths are.”

I hope you enjoy the article series. Please share with your friends and colleagues and if you have any questions or comments please feel free to Contact Me directly.

PART 1 Nov. 15, 2011
Management of Low Back Pain - Something Has to Change

Background:

Since launching Research Review Service 5 years ago, I have written and edited numerous reviews on clinical research dealing with low back pain (LBP). As RRS readers know, each review starts with pertinent background information relating to the topic at hand, including the general state of the literature, epidemiology, statistics and so on. For LBP specifically, the content of the background information sections remains consistent and concerning. It normally reads something like this: 80% of people get LBP at some point, delivering an accurate anatomical diagnosis is very challenging in most cases, treatment options abound yet misinformation is common, 10% of LBP patients become chronic disasters resulting in thousands of lost work days and reduced productivity, billions of dollars in costs – you get the idea.

While generating and editing research reviews for weekly posting on RRS, our team makes every attempt to remain unbiased in our presentation of a balanced view of the literature and how to rationally integrate current evidence into practice.  This is what RRS has always delivered to its readers. Having said that, I hope you’ll indulge my desire to editorialize in this article.  I’m frustrated and want to initiate some serious discussion about how we, EVERYONE, approaches and manages LBP. Something has to change!

Journals spanning the disciplines of medicine, physiotherapy, chiropractic, rehabilitation and manual therapy consistently publish clinical trials, systematic reviews, meta-analyses, and clinical practice guidelines to help us clinically evaluate and manage LBP. However, when I turn the pages of these same journals to reports on patient outcomes and healthcare expenditures, I can’t help but wonder if ANYONE is reading this stuff?

It seems that the norm for LBP management has deteriorated (or perhaps failed to evolve congruently with emerging evidence) to a point where overworked family doctors frequently prescribe excessive doses of strong pain medications, refer for countless specialist consults and over-image almost every LBP case. Surgeons apply the ‘cut or nothing’ approach and then hope patients seek some type of ‘rehab’. Manual-medicine providers of all stripes look at patients only as dollar signs and addict them to passive therapies. Occupational health providers apply inappropriate outcome measures and impede recovery - this list could go on. 

I am generalizing of course, but everyone involved is guilty in some regard and huge sums of money are being squandered. The literature is clear on this. Who suffers? I would argue our patients do, first and foremost.  They are vulnerable and looking for answers.  They are often misinformed and at risk of developing something serious and long-lasting out of something completely manageable. But I also think we as (insert your profession here) suffer as well. Our reputations are at stake, and the stereotypes that we all find so offensive are being rightfully proliferated, in most cases due to our actions or biases. Is the health care community as a whole staying current and integrating research responsibly to improve practice patterns, better serve patients, and spare precious dollars? I think the answer is a resounding NO! Lastly, I think we are all affected as tax-paying citizens. Health care is costly, and the money has to come from somewhere.

The Problem:

Let me boil this down for you: LBP is becoming a modern-day epidemic. In fact it could easily be argued it already is.  A multidimensional, complex and often enigmatic affliction, it is a massive problem and extremely costly on many economic and societal levels. LBP affects everyone, whether you have suffered it yourself, know someone who has, treat LBP clinically to make a living, or pay for LBP directly or indirectly via your job, your region’s healthcare system, or taxes. 

To illustrate, from 1994 to 2007 (6, 7): MRIs have increased 307%, spinal fusion surgery has increased 204%, spinal injections have increased 629%, and opiate use has increased 423%. To put this in perspective, during this time period the corresponding patient population increased by only 12%! Despite these alarming numbers, patient outcomes are worsening and the consequences of LBP are growing ominously on many fronts, affecting ALL of us.

Something must be done!  Things have to change!  This is not sustainable!

We, as a collective of clinicians, patients, advocates, policy makers and politicians, must wake up and address this issue.  I am not just referring to discovering a new device, gadget or gimmick.  Late-night television has enough of those empty promises. I am also not talking about the meteoric and improbable rise of one single intervention or treatment modality for ‘curing’ LBP – it isn’t that simple and LBP is not homogenous as a clinical entity.  We know this now.

What I am talking about is a collective, conscious, consistent, rational, evidence-informed and patient-centered approach to LBP with the important goals of better serving and empowering our patients, raising our cultural authority and promoting fiscal responsibility on all levels.  Such an approach may require many of us to challenge the way we think, or alter our current practice patterns.  For some, such a shift in thinking is long overdue.

Let me be clear. I am only one clinician. I don’t have all the answers and am not in a position to implement wide-spread change to our healthcare system.  No one can do this alone, but as a collective, we can be a powerful force for change. In order to succeed, commitment from many professionals with diverse backgrounds will be required, in addition to the rational integration of results from the vast body of published literature on LBP.  With the addition of our clinical expertise and common sense, change is more than possible. 

Via Research Review Service, I review a number of specific clinical studies and review papers.  In the next section of this article, I will speak more in generalities with the intent of broadening the discussion on this topic.  I will discuss current issues in LBP management and research, and review some common themes and recommendations from recently published clinical practice guidelines spanning the globe. Many key factors are indeed, general concepts.  Having said that, I will reference a number of recently published summaries, systematic reviews and position statements from many of the world’s leading experts on LBP to illuminate the discussion.  I propose that the problem of poor results for LBP management in primary care is more an issue of poor research implementation versus a lack of insight about potentially helpful treatments and approaches.  Positive change is necessary, and we as evidence-informed manual medicine providers can play a key role.

PART 2 Nov. 22, 2011
Current Issues in Low Back Pain Management & Research

As you know, LBP remains an epidemic, a contemporary healthcare crisis. Despite a large volume of research being conducted to improve LBP care, a recent meeting of leading experts from around the world reached the consensus that overall, the situation has deteriorated (2). In fact chronic, disabling LBP has increased roughly five-fold in the last 15 years! This same group suggested that a “low back pain medical industrial complex” reigns, rather than a system of health improvement. Concerns about inappropriate LBP management and iatrogenesis abound, and with good reason:
  • It is well established that most imaging findings, particularly degenerative changes, correlate poorly with clinical presentation (many people still fail to grasp this concept). Despite this, radiographic and advanced imaging is routinely ordered for many LBP patients in primary care settings. Chiropractors are often guilty in this regard as well. Inappropriate imaging can lead to misdiagnosis, inappropriate management including potentially unnecessary surgery, poor outcomes and high cost (15). Imaging for LBP appeared on a recently published list of overused clinical activities, with an estimated direct cost of over $175 million in the United States alone (1)!
  • Opioids are now the most commonly prescribed drug category in the United States and are highly utilized for LBP. This would be acceptable if the benefits outweighed the risks. They do not. Prescription rates for these drugs continue to rise, despite evidence they are not superior to cheaper, safer treatments for LBP, such as NSAIDs (4, 5). Further, high doses are often prescribed for long periods of time, raising the risk of dependence and other side effects, though leading experts now suggest the risks of long-term opioid use extend well beyond addiction (9). This is a serious issue, as opioids are now also the leading cause of unintended death via overdose in the United States (13). Episodic back pain, even when acute, should not result in a prescription drug addiction!
  • Anti-depressants are also commonly prescribed for chronic LBP, despite convincing, consistent, high-level evidence indicating they do not outperform placebos for LBP itself, and likely do not even reduce depressive symptoms associated with LBP (4, 5)!
  • Many non-medical health care providers – chiropractors, physiotherapists etc. – continue to employ a ‘one trick’ approach with LBP patients and assume LBP is a homogenous condition. For example, some use only spinal manipulation, others only ultrasound on every LBP patient. This in spite of evidence suggesting distinct subgroups of LBP patients exist which likely respond preferentially to different treatments (12). This work is ongoing and there is not yet consensus on which classification system is superior (14), but evidence-informed clinicians have been utilizing this information for years already. Such tunnel vision is, in my opinion, as damaging as any other concern discussed here. It needs to stop.
Other concerns about the state of LBP management and research in general include:
  • Current care patterns for LBP are fragmented, with patients presenting to primary care, manual medicine providers or even secondary specialists (surgeons, neurologists etc.).
  • Patients often expect a complete elimination of pain while evidence-informed practitioners know functional improvement is paramount and often more realistic. This discordance can impose unreasonable expectations, shift the focus away from improving function, and place undue expectations and pressures on treating physicians. This may lead to the current situation, where many experts agree LBP patients are being over-treated in general (9, 10).
  • Return to work (RTW) is a major issue in LBP management and occupational medicine in general. Current evidence suggests RTW is better predicted with workplace and societal factors (work environment, compensation system, union issues etc.) than biomedical or biomechanical variables. Despite this, family physicians or manual therapists are often responsible for determining when a patient can return to work in the absence of a multidisciplinary approach incorporating these factors.
  • Clinical research is often conducted on highly-selected samples in rarefied settings with an inordinate level of resources, which is difficult to generalize to more typical settings and where the interventions may not be practical, available, or affordable. We should all remember evidence-based medicine is a three-pronged strategy, incorporating current evidence, clinical experience and patient preference. This is where integrating research results in a realistic and rational way can assist in the management of many conditions including LBP (this has always been an overarching goal of Research Review Service!).
  • Commonly used outcomes such as return to work, improvement in self-reported function and pain resolution have been shown to follow different patterns and do not always correlate.
  • The search for definitive predictors of poor outcome remains incomplete. Research is underway to develop and validate pragmatic ways to identify workers and patients at risk for poor outcomes so treatment can be tailored accordingly. These studies suggest a shift from the prior focus of identifying red flags (which, although important, does not in and of itself guarantee quality treatment), to a more holistic investigation of factors which can influence the recovery of an individual.
What do current Clinical Practice Guidelines tell us?

Ten Clinical Practice Guidelines (CPGs) have been published in various countries around the world in the last 10 years or so. CPGs are developed to synthesize the best available evidence and make recommendations regarding the assessment and management of a clinical condition. There are some big brains involved in putting these together – high-level researchers, clinicians and experts – people we should listen to. There is a high level of consistency among these ten CPGs and their methodological quality is high as a collective. Experts suggest one of the major deficits in current management patterns for LBP is a lack of uptake of CPG recommendations. I agree, and this pattern must change!

Taken together, some common general recommendations and guidelines consistently emerge which all health care providers should keep in mind for LBP, regardless of professional background (3, 17):

Assessment & Triage of LBP:
  • Diagnostic Triage: In general, LBP patients can be effectively divided into two broad categories – nonspecific (majority), and specific (small minority). Other guidelines further differentiate into nonspecific, radicular, or serious pathology.
  • The main goal in assessing LBP patients is to rule out potentially harmful spinal pathology even though only about 1% of patients will have such a condition (the small minority mentioned above). Common red flags are discussed across CPGs and include age greater than 50, history of cancer, cauda equina symptoms, urinary retention, history of steroid use, unexplained weight loss, night pain, and so on. In these rare cases, advanced imaging and further clinical work up is clearly required. For the remaining 99%, a thorough history and appropriate physical examination should suffice and preclude the need for imaging or specialist involvement.
  • A second goal is to rule out rare but specific causes of LBP other than serious spinal pathology. This refers to such conditions as Ankylosing Spondylitis, kidney pathology, etc.
  • Substantial neurological involvement should also be evaluated. This can be done primarily via thorough history and physical examination. Routine imaging is not recommended unless patients fail to respond to conservative care. This is one recommendation rarely followed by many health care providers.
  • Pain severity and functional limitations should also be addressed. No consensus exists among the CPGs regarding which questionnaires should be utilized for these aspects.
  • Practitioners in all disciplines should also evaluate the risk of chronicity, as this small percentage of patients account for a disproportionate amount of health care spending. These are biopsychosocial factors such as anxiety, depression, work dissatisfaction etc.
Management of LBP:
  • Acute LBP: Advise patients to stay active (another one that is often ignored!), reassure them and provide education about LBP; employ a short course of paracetamol/acetaminophen or NSAIDs; spinal manipulation; NO bed rest
  • Chronic LBP: Provide advice to stay active, some form of exercise (no consensus), perhaps weak opioid medications or NSAIDs (preferably), spinal manipulation. No CPGs recommend bed rest, decompression surgery, back supports, biofeedback, heat/cold, traction or ultrasound. Recommended secondary interventions include cognitive behavioral therapy, multidisciplinary rehabilitation and adjunctive analgesics.
  • LBP with substantial neurological involvement: Advise patients to stay active, reassure them and provide education about LBP; employ a short course of paracetamol/acetaminophen or NSAIDs +/- muscle relaxants; spinal manipulation; NO bed rest. Back exercises, acupuncture and massage may also help. No CPGs recommended back supports, traction, heat/cold or ultrasound. Recommended secondary interventions include multidisciplinary rehabilitation, behavioral therapy, stronger analgesics, steroid injections or decompression surgery in appropriate cases.
General:
  • No CPG has stated that it is necessary, or even beneficial, to identify a specific anatomical structure involved in LBP if serious pathology or neurological involvement has been adequately ruled out.
  • It has also been consistently suggested that ordering needless diagnostic tests may INCREASE the chance of chronicity. Patients and practitioners should understand that in many cases of LBP, assessment is a more feasible objective than diagnosis, as a specific pain-generating structure can rarely be definitively identified.
  • All CPGs clearly state that most cases of acute LBP improve substantially within a few weeks and recommend against early imaging and aggressive treatment regimens.
  • Practitioners should ensure patients focus on function rather than pain, and all attempts should be made to maintain active working status.
Overall, management of LBP should focus mostly on patient education, with short-term use of paracetamol/acetaminophen, NSAIDs, or SMT for symptomatic relief of acute LBP, with the judicious addition of opioid analgesics, back exercises, behavioural therapy, or acupuncture for additional symptomatic relief for chronic LBP. It is well documented that adherence to these recommendations leads to superior patient outcomes and lower costs. However, an equal amount of literature indicates primary care physicians, chiropractors, physiotherapists and medical specialists routinely fail to comply with these simple recommendations (8, 9). A combination of professional bias, inappropriate patient expectations, and perverse financial incentives may contribute to over-aggressive management.

Most concerning is the overuse of advanced imaging, opioid prescribing and passive physical therapy modalities or manual techniques (10). Further, many physicians still recommend bed rest and feel return to work should not occur until full pain resolution is achieved (11), despite ample evidence that these approaches are harmful for LBP patients! Again, we as a healthcare collective must consciously act for the benefit of our patients. This cannot wait.

PART 3 Nov. 29, 2011
An Opportunity to Lead the Way

The first 2 parts of this article series discussed various aspects of the healthcare crisis of low back pain: its prevalence and impact, current shortcomings in clinical management, iatrogenesis concerns, research issues, and treatment recommendations from current, international clinical practice guidelines. I also discussed how, as a collective, we as healthcare providers are failing to integrate simple, evidence-informed recommendations into practice while patient outcomes worsen and costs skyrocket. I hope to provide, at least in part, a reasonable way forward…

An Opportunity to Lead the Way

My goal in writing this article series was not to be discouraging, but rather to inspire healthcare providers like you to seize the opportunity and lead the way in caring for LBP for coming generations.  We now have the knowledge base to have a meaningful and effective impact on patients with LBP.  I am not implying that we previously did not, but in order to excel, impress and succeed we simply must continue to adapt our approach, upgrade our skills and act. Clinging to professional or personal bias, historical concepts, or laziness can no longer suffice (if it ever did). Our patients deserve better.

I think Dr. Richard Deyo, a well-respected and well-published clinician, summarized it best (9): "…patients and the public need more unbiased information about back pain management, so expectations are congruent with clinical realities.  Too often, product marketing, media reporting, and our own wishful thinking seem to promise definitive answers and a pain-free life. Both doctors and patients need expectations that are more realistic, more accurate language, and clear-eyed sharing of management decisions. Somehow, we need to get better congruence between what we say and what we do, channelling money to where our mouths are."

It is hard for some professionals to grasp the concept that we may have contributed to this crisis.  That is understandable, yet not productive going forward.  Improving the current state of LBP care is possible, but this shift must be guided by unbiased interpretation of existing literature, continued integration of new research, commitment and implementation by individual clinicians, and support from healthcare policy makers and professional associations. So where do we go from here?

The War on Misinformation

Although I feel we must focus on factors within our control, we must acknowledge that patients are constantly exposed to inappropriate messages about low back pain. It is a huge problem, a barrier we face daily and must address early in a clinical encounter. Rational education and clear communication are paramount. It could be argued the majority of this misleading information comes from pharmaceutical companies in the form of oversimplified representations of LBP (Is anyone else tired of seeing the 'glowing red spot on the low back'?) or inaccurate representations of pain physiology ('targeting the exact site of pain'). Unfortunately, this downward force is likely to continue since there are large sums of consumer dollars up for grabs, and few regulations to govern their advertising content. 'Clinically proven' is not always as it sounds. 

Pharmaceutical companies are running a business, first and foremost, and as such have little commitment to the well-being of patients as individuals when compared to the interest of their shareholders. This is a clear conflict of interest we cannot change. I feel we have a higher responsibility to our patients and possess the skills to overcome this, so this should not be used as an excuse.

What we can control is the information and advice we provide for our patients. This is an aspect of good clinical care which is often neglected, or even contaminated with blatant lies that suit the interest of the clinician, rather than the patient. Taking a few minutes to listen, provide reassurance and advice to stay active in conjunction with some simple education about LBP is not only helpful, but in line with current evidence. Is this something you do currently? Patients look to us for guidance, reassurance and expertise, yet many practitioners continue to provide only biased, historical or financially-driven messages in the absence of rational clinical examination or monitoring of responses to treatment.

For example, prolonged, excessive treatment plans are not only in direct contradiction to existing guidelines, they harm our reputation on many fronts. Many practitioners are more concerned with the patient attending and paying for numerous treatments, completely ignoring the opportunity to grow their practice through efficient, rational clinical management. When a patient seeks our care, it should be about their interests, not ours. Professionals in all disciplines are guilty of ignoring this professional duty and it must stop for us to advance our culturally authority. Make it start (or hopefully, continue) with you.

Rational, Evidence-Informed Patient Care

In communicating with colleagues over the years, it has become apparent to me that many are still intimidated by the concept of 'Evidence-Based Medicine' (EBM). This term implies that 'evidence' (in whatever form) is all that matters. This is inaccurate and not reflective of the original EBM model proposed by Dr. Sackett and colleagues over 15 years ago (18, or any of Sackett’s publications). The model proposes that EMB is a three-pronged approach to clinical practice and patient care, including equal contributions from: 1) the best available scientific evidence; 2) patient preference; and 3) the experience of the clinician. Taking the entire model into consideration, I feel a more appropriate term in most cases is evidence-informed care. I feel this better reflects the reality of clinical practice, while still emphasizing the importance of integrating current, applicable scientific evidence. One of the goals of Research Review Service is to take the enormous body of published literature and refine it to concise, rational, relevant clinical pearls you can apply in your office each week. I feel this objective is an important component in fostering evidence-informed care and I am confident RRS does this very well. 

A final word on LBP…

Patients with LBP, whether acute or chronic, need our help.  We, as well-trained, up to date and highly-skilled manual therapists – chiropractors, physiotherapists, osteopaths, and others – are perfectly positioned and available to provide appropriate assessment, diagnostic and therapeutic interventions in a cost-effective manner. Currently, it seems patients frequently turn to their medical doctors hoping for pain relief and appropriate management. According to the literature, this is not happening in accordance with current guidelines and standards. Please understand that this article is not meant to pit us against medical doctors or create inter-professional tension. 

That’s not what this is about.  Every profession has its strengths and I feel that LBP and musculoskeletal medicine in general, is ours. Our medical colleagues in many parts of the world are simply overwhelmed and undereducated on musculoskeletal disorders. LBP is no different even though family physicians are confronted with this condition frequently. According to the literature, the current trend of prescribing endless imaging, heavy drugs and specialist referrals is not benefiting most patients. It is not evidence-informed care. This is our opportunity.

As I reviewed the studies referenced in this article series – all high-level research published very recently – I tried to pull out the most pertinent points which illuminated this problem and summarized the most current recommendations for LBP care. You are hopefully already implementing these strategies. If not, I hope reading this article has stimulated some self-evaluation and critical thinking for positive change to help you with your next low back pain patient. Guidelines represent a solid starting point, but we must remember each patient is unique, and we must base treatment decisions on not only evidence, but their personal preference and our clinical expertise, keeping in mind the ever-present cost issue. 

The well being of our patients, the future financial and societal impact of LBP, our cultural authority and success as a discipline rests in the hands of those who treat patients. That is a big responsibility and the future is bright if we choose a reasonable, evidence-informed course of action. I encourage you to keep a rational, open and critical eye on the literature, draw on your clinical experience, integrate your skills, individualize your treatment approach, and really listen to your patients. Only good things will come of this if we work together.

In closing…

I truly appreciate the time you have taken to read this article series.  One thing I love most about running Research Review Service is the chance to engage my colleagues in rational discussion, while helping those in practice, on the front lines doing their best to help patients, integrate the latest scientific evidence with their clinical prowess to enhance patient care. I believe LBP represents one of the biggest crises in modern healthcare, while also presenting our greatest opportunity for growth.  I hope you choose to subscribe to RRS and enjoy the weekly reviews we post each week – many of the important points and concepts covered in this article have been reviewed in much detail for subscribers since RRS was launched in 2006.  We now have over 400 reviews in our database.  No one can read, interpret and clinically apply every pertinent piece of new research, so let us help you.

If you have any questions about RRS or this article series, please Contact Me directly.

Best Regards,

Dr. Shawn Thistle

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References:
  1. The Good Stewardship Working Group. The “top 5” lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011; 171(15): 1385-1390.
  2. Pransky G, Borkan JM, Young AE & Cherkin DC. Are we making progress? The Tenth International Forum for Primary Care Research on Low Back Pain. Spine 2011; 36(19): 1608-1614.
  3. Dagenais S, Trico 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: 514-529.
  4. Kuijpers T, van Middelkoop M, Rubenstein SM et al. A systematic review of the effectiveness of pharmacological interventions for chronic non-specific low back pain. European Spine Journal 2011; 20: 40-50.
  5. White AP, Arnold PM, Norvell DC et al. Pharmacologic management of chronic low back pain: Synthesis of the evidence. Spine 2011; 36(21S): S131-S143.
  6. Martin BI, Deyo RA, Mirza SK et al. Expenditures and health status among adults with back and neck problems. JAMA 2008; 299: 656-64.
  7. Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? Journal of the American Board of Family Medicine 2009; 22: 62-8.
  8. Ivanova JI, Birnbaum HG, Schiller M, et al. Real-world practice patterns, health-care utilization, and costs in patients with low back pain: the long road to guideline-concordant care. Spine Journal 2011; 11: 622–32.
  9. Deyo RA. Commentary: Managing patients with low back pain: Putting money where our mouths are not.  Spine Journal 2011; 11: 633-635.
  10. Carey TS, Freburger JK, Holmes GM, et al. A long way to go: practice patterns and evidence in chronic low back pain care. Spine 2009; 34: 718-24.
  11. Buchbinder R, Staples M, Jolley D. Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine 2009; 34: 1218-26.
  12. Fourney DR, Andersson G, Arnold PM et al. Chronic low back pain: A heterogenous condition with challenges for an evidence-based approach. Spine 2011; 36(21S): S1-S9.
  13. Okie S. A flood of opioids, a rising tide of deaths. New England Journal of Medicine 2010; 363: 1981-5.
  14. Fairbank J, Gwilym SE, France JC et al. The role of classification of chronic low back pain. Spine 2011; 36(21S): S19-42.
  15. Flynn TW, Smith B & Chou R. Appropriate use of diagnostic imaging in low back pain: A reminder than inappropriate imaging may do as much harm as good. Journal of Orthopaedic and Sports Physical Therapy 2011; 41(11): 838-846.
  16. Lin CC, Haas M, Maher CG et al. Cost-effectiveness of general practice care for low back pain: A systematic review. European Spine Journal 2011; 20: 1012-1023.
  17. Koes BW, van Tulder M, Lin CC et al. An updated overview of clinical guidelines for the management of nonspecific back pain in primary care. European Spine Journal 2010; 19: 2075-2094.
  18. Haynes RB, Sackett DL, Gray JM et al. Transferring evidence from research into practice: 1. The role of clinical care research evidence in clinical decisions. ACP Journal Club 1996; 125(3): A14-6.
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