BRIEF REPORT: Physicians’ Initial Management of Acute Low Back Pain Versus
Influence of Sciatica
Barbara S. Webster, BSPT, PA-C,
Theodore K. Courtney, MS, CSP,
Simon Matz, MS,
David C. Christiani, MD, MPH, MS
Center for Disability Research, Liberty Mutual Research Institute for Safety, Hopkinton, MA, USA;
Quantitative Analysis Unit, Liberty Mutual
Research Institute for Safety, Hopkinton, MA, USA;
Center for Safety Research, Liberty Mutual Research Institute for Safety, Hopkinton, MA,
Department of Environmental Health, Occupational Health Program, Harvard School of Public Health, Boston, MA, USA.
BACKGROUND: Little information is available on physician character-
istics and patient presentations that may influence compliance with
evidence-based guidelines for acute low back pain.
OBJECTIVE: To assess whether physicians’ management decisions
are consistent with the Agency for Health Research Quality’s guideline
and whether responses varied with the presentation of sciatica or by
DESIGN: Cross-sectional study using a mailed survey.
PARTICIPANTS: Participants were randomly selected from internal
medicine, family practice, general practice, emergency medicine, and
occupational medicine specialties.
MEASUREMENTS: A questionnaire asked for recommendations for 2
case scenarios, representing patients without and with sciatica, re-
RESULTS: Seven hundred and twenty surveys were completed (re-
25%). In cases 1 (without sciatica) and 2 (with sciatica),
26.9% and 4.3% of physicians fully complied with the guideline, re-
spectively. For each year in practice, the odds of guideline noncompli-
ance increased 1.03 times (95% confidence interval [CI]
1.01 to 1.05)
for case 1. With occupational medicine as the referent specialty, general
practice had the greatest odds of noncompliance (3.60, 95% CI
to 7.40) in case 1, followed by internal medicine and emergency med-
icine. Results for case 2 reflected the influence of sciatica with internal
medicine having substantially higher odds (vs case 1) and the greatest
odds of noncompliance of any specialty (6.93, 95% CI
1.47 to 32.78),
followed by family practice and emergency medicine.
CONCLUSIONS: A majority of primary care physicians continue to be
noncompliant with evidence-based back pain guidelines. Sciatica dra-
matically influenced clinical decision-making, increasing the extent of
noncompliance, particularly for internal medicine and family practice.
Physicians’ misunderstanding of sciatica’s natural history and belief
that more intensive initial management is indicated may be factors un-
derlying the observed influence of sciatica.
KEY WORDS: back pain; guidelines; practice variation; clinical vi-
gnette; decision making.
J GEN INTERN MED 2005; 20:1132–1135.
ow back pain affects up to 80% of the working population
during their lifetime and is the second most common rea-
son for physician visits
and for work disability.
accounts for an estimated $25 billion in annual medical costs
in the United States.
Factors related to the extensive burden of back pain may
include variations in physicians’ clinical management as the
etiology of back pain is unclear.
Clinical practice guidelines
have been systematically developed to improve health care
quality and reduce ineffective treatments. A number of evi-
dence-based guidelines for the clinical management of acute
back pain in primary care have been published since the first
including the Agency for Healthcare Research and
Quality (AHRQ, previously named the Agency for Health Care
Policy and Research) guideline in 1994.
More recent guide-
lines are based on newer evidence but have similar diagnostic
and therapeutic recommendations to the AHRQ guideline.
All guidelines recommend an initial evaluation to identify
the approximately 5% of patients who present with ‘‘red flags.’’
Red flags are those findings that suggest significant pathology
(i.e., vertebral fracture, tumor, infection, cauda equina syn-
drome, or serious nonspinal conditions) that require diagnos-
tic studies and/or specialty referral as part of initial
After ruling out such serious conditions, cases are cate-
gorized as nonspecific back pain or sciatica (approximately
85% and 5% of cases, respectively). Disabling symptoms are
expected to resolve in up to 90% of patients within the first
month, including over 50% of those with sciatica.
line intent is to change the care focus for both categories of
back pain from pain relief to improved activity tolerance, and
to limit unnecessary diagnostic and clinical treatment inter-
ventions during this period.
Despite the proliferation of evidence-based back pain
guidelines, prior studies, based on chart reviews or physician
surveys, found a lack of consensus and compliance with
However, these studies were based either on a small
sample size, a single specialty group, or were completed more
than a decade ago. This study’s purpose was to assess the ex-
tent to which the clinical decision-making in a more recent,
national sample of primary care physicians was consistent
with the guideline, and whether responses varied with the
presentation of sciatica or by physician characteristics.
Received for publication May 10, 2005
and in revised form June 13, 2005
Accepted for publication June 20, 2005
The Liberty Mutual Research Institute for Safety is owned and
operated by the Liberty Mutual Insurance Company. The Institute con-
ducts original scientific investigations into the causes and prevention of
job-related injuries and disability. All research is published in peer-re-
viewed journals in science, engineering, or medicine.
Conference: Presented in part in a poster at the Montreal Interna-
tional Forum V for Primary Care Research on Low-Back Pain, May 2002.
Address correspondence and reprint requests to Webster: Liberty Mu-
tual Research Institute for Safety, Center for Disability Research, 71
Frankland Road, Hopkinton, MA 01748 (e-mail: barbara.webster@liber-