Lower back pain is a common symptom in adults and is the leading cause of disability globally (1) It has been estimated that 16% of the Australian population (four million people) have back pain, and approximately 70 to 90% of people will develop back pain at some stage in their life (2). Known risk factors include female gender, smoking, poor socio-economic status, a sedentary lifestyle, genetic predisposition, joint trauma and obesity (2, 3). Work-related back pain is also common, affecting people in occupations such as construction, community service and health care (4). Back pain accounts for the second leading cause of disease burden in Australia, impacting on activities of daily living and mental health (2). From an economic perspective, there were 175,136 hospitalisations due to back problems in 2016 to 2017 (2) and in 2012, the direct cost of managing back pain was estimated to cost $4.8 billion (5).
Back pain has been categorized into three main types, which include specific spinal pathology, radicular syndromes and non-specific back pain. Among them, non-specific back pain represents the majority (90 to 95%) of cases, followed by radicular syndromes (5 to 10%) and specific spinal pathology (less than one percent) (6). For appropriate management of back pain, it is important to exclude red flags such as young and elderly patients, signs of infection or inflammatory spondyloarthropathy, features of cauda equina syndrome, neurological deficits, history of malignancy, significant trauma, unexpected weight loss and patients on corticosteroids (5). In the absence of these features, unnecessary imaging investigations lead to potential exposure to ionising radiation and the financial cost to the patient and health care system and increased rates of spinal surgeries (7). In 2013, approximately $220 million was reimbursed by Medicare for spinal imaging (5). In addition, there may be incidental findings that do not have clinical significance. One study demonstrated that over fifty percent of asymptomatic patients aged 30-39 had signs of disc degeneration, disc height loss and protrusion (8).
Evidence based guidelines recommend patient education, avoiding bed rest, exercise therapy and return to normal activities. “Yellow flags” such as beliefs that activity is harmful, sickness behaviours, low mood, social withdrawal, requesting non-evidence based treatment, previous back pain, work issues and lack of social support (5) should also be addressed to reduce the progression to chronic pain. Approximately 40% of patients recover within six weeks and 14% develop chronic back pain (5).
For acute lower back pain, pharmacotherapy is not recommended as first-line management. Paracetamol is recommended, though it has not shown to be more effective than placebo (5). Non-steroidal anti-inflammatory drugs can be used for short-term pain however side effects must be taken into account (5). Opiates are commonly prescribed but are associated with issues such as tolerance and dependency and therefore should be avoided (1). Pain secondary to nerve root compression may be alleviated with tricyclic antidepressants, anticonvulsant agents and serotonin noradrenaline reuptake inhibitors (5). A randomised control trial found that gabapentin did not provide analgesic effects and was associated with increased side effects (9). Spinal corticosteroid injections only provide short-term pain relief for radicular pain (5).
Epidemiological studies from overseas have shown that health professionals' beliefs of back pain are associated with patients’ understanding and adherence to treatment guidelines for managing back pain (10). In Australia, it is not yet well-established whether young health professionals have a good understanding of the management of acute non-specific lower back pain. In this study, we aim to evaluate this by surveying final year medical students, junior medical officers and registrars (medical, GP and ED) with a questionnaire of ten multiple choice questions. Specific demographic data such as sex, age and previous degrees was also collected. The research findings will enable us to improve the understanding and management of lower back pain and improve patient outcomes.
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