BRIEF REPORT: Physicians’ Initial Management of Acute Low Back Pain Versus
Influence of Sciatica
Barbara S. Webster, BSPT, PA-C,1Theodore K. Courtney, MS, CSP,2,4Yueng-Hsiang Huang,
PhD,3Simon Matz, MS,2David C. Christiani, MD, MPH, MS4
1Center for Disability Research, Liberty Mutual Research Institute for Safety, Hopkinton, MA, USA;2Quantitative Analysis Unit, Liberty Mutual
Research Institute for Safety, Hopkinton, MA, USA;3Center for Safety Research, Liberty Mutual Research Institute for Safety, Hopkinton, MA,
USA;4Department 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-
sponse rate=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=1.75
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.
son for physician visits1and for work disability.2Back pain
accounts for an estimated $25 billion in annual medical costs
in the United States.3
Factors related to the extensive burden of back pain may
include variations in physicians’ clinical management as the
etiology of back pain is unclear.1,4Clinical 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
in 1987,5including the Agency for Healthcare Research and
Quality (AHRQ, previously named the Agency for Health Care
Policy and Research) guideline in 1994.6More recent guide-
lines are based on newer evidence but have similar diagnostic
and therapeutic recommendations to the AHRQ guideline.7
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.8The guide-
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.6
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
them.9–13However, 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.6
ow back pain affects up to 80% of the working population
during their lifetime and is the second most common rea-
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-
A 2-page questionnaire was developed to assess physicians’
clinical approach to 2 case scenarios of back pain. Scenarios
(Appendix) were designed to represent different diagnoses:
case 1 representing nonspecific back pain and case 2 repre-
senting sciatica with neurologic findings. However, neither
case presented with ‘‘red flags;’’ therefore, during the first
month of care, the guideline recommendations for both require
only minimal clinical intervention, and neither requires diag-
nostic testing. Physicians were asked to indicate the diagnostic
and treatment modalities they would order for initial manage-
ment of each case (listed in Table 1) and whether they would
consider specialty or surgical referral. Demographic informa-
tion (age, gender, years in practice, and frequency treating
back pain patients) was also requested.
Six hundred physicians were randomly selected within each
specialty group representing providers likely to treat acute
back pain: family practice, general practice, internal medicine,
emergency medicine, and occupational medicine (3,000 for the
initial mailing) from the 1999 American Medical Association
(AMA) Directory of Physicians.14Two additional mailings to
nonrespondents with replacement were conducted. Respond-
ents who returned completed surveys were entered in a draw-
ing for one $500 cash prize. Human subject approval was
received from the Human Subjects Committees of the Liberty
Mutual Research Institute and the Harvard School of Public
McNemar’s test was performed to compare physicians’ indi-
vidual intervention responses to the 2 different levels of back
pain severity. Variation in guideline noncompliance (selecting
at least 1 intervention that was demonstrated to be ‘‘inconclu-
sive’’ or ‘‘not recommended’’) by physician characteristics (age,
gender, specialty, years in practice) was assessed using mul-
tiple logistic regression.15
Of the 3,238 physicians solicited over 3 mailings, 397 surveys
were excluded because of wrong addresses or because re-
spondents were not practicing in primary care, did not treat
back pain, or failed to complete demographic or case ques-
tions. Of the remaining 2,851 questionnaires, 720 were com-
pleted (25% response rate). Response rate by specialty ranged
from 18% for general practice to 34% for family practice.
Males comprised 81% of the respondents. Mean and me-
dian respondent ages were 49.3 and 48.0 (range, 27 to 85
years). The mean and median practice durations were 20.3
and 19.0 years (range, 1 to 58 years). Of the overall sample,
family practice was the best represented (27%) and general
practice the least represented (14%). Respondents practiced in
48 states and the District of Columbia, with an equal distri-
bution across the 4 U.S. Census regions.
Table 1 presents the percentage of responses by interven-
tion, the McNemar’s test results, and guideline recommenda-
tions.6Sciatica was significantly associated with increased
noncompliance for the majority of interventions.
In cases 1 (without sciatica) and 2 (with sciatica), 26.9%
and 4.3% of the physicians fully complied with the guideline,
respectively. Years in practice was included in the multivariate
logistic regression analysis as it better reflects clinical experi-
ence than age.
In case 1, differences in years in practice and specialty
group were significant (Table 2). For each year in practice, the
odds of guideline noncompliance increased 1.03 times (95%
confidence interval [CI]=1.01 to 1.05) for case 1 with similar
odds for case 2.
Occupational medicine was selected as the referent spe-
cialty based on the best compliance (36.1% and 12.3% full
compliance for cases 1 and 2, respectively). General practice
had the greatest odds of noncompliance (3.60, 95% CI=1.7 to
7.40) in case 1, followed by internal medicine and emergency
medicine. Results for case 2 reflect the influence of sciatica.
Internal medicine had substantially higher odds (vs case 1)
and the greatest odds of noncompliance of any specialty (6.93,
Table1. Comparison of Percentage‰Responses to the Two Cases
and AHRQ Guideline Recommendationsk(N=720)
Intervention Case 1
CT without contrast
Patient information and
Education on back pain
Bed rest for ?3d
Bed rest 43d
Opioids, short course
Trigger point injections
Epidural steroid injection
Refer to specialist
?Po0.05 based on McNemar’s test.
wPo0.01 based on McNemar’s test.
zPo0.001 based on McNemar’s test.
‰Percentage based on number of completed responses per individual in-
tervention, with 0.7% to 4.0% and 2.4% to 6.1% missing responses per
individual intervention in cases 1 and 2, respectively.
kAccording to guideline recommendations: shaded text interventions, in-
conclusive or not recommended; nonshaded interventions, optional, ac-
ceptable, or recommended.
Webster et al., Management of Acute Low Back Pain
95% CI=1.47 to 32.78), followed by family practice and emer-
gency medicine. Gender was not associated with noncompli-
ance in either case.
Surveyed physicians departed from the AHRQ guideline to
some extent for the case with nonspecific back pain. However,
those in general practice and internal medicine and, to a lesser
extent, those in emergency medicine, were significantly more
likely to choose at least 1 nonevidence-based intervention for
patients without sciatica.
In case 2, sciatica dramatically influenced clinical deci-
sion-making with almost all physicians selecting at least 1
nonevidence-based intervention. Increases in noncompliance
within internal medicine and family practice were particularly
substantial. Between-specialty differences were also pro-
nounced, even when controlling for years in practice and gen-
der. While a diagnosis of sciatica might suggest more intensive
clinical intervention, the guidelines for the first month still
recommend conservative interventions to allow time for symp-
tom resolution (which occurs in over 50% of patients with sci-
atica) and for the patient to overcome activity limitations.6
More intensive management approaches may inhibit activity
restoration and have been shown to prolong disability.9
The significance of years in practice in noncompliance is
consistent with the results of a recent systematic review of
empirical studies. More-experienced physicians were found to
demonstrate less knowledge, be less likely to follow standards
of practice, and have less successful outcomes.16
The present study sampled a national population of pri-
mary care providers and was not limited to 1 specialty group or
health plan. The response rate was similar to a previous survey
of nonsurgical physicians regarding back pain treatment (25%
to 33%),11and was within the reported range of 11% to 100%
for physician surveys.17Gender and age closely matched the
years),18and respondents were similarly distributed across
major U.S. Census regions. These sample characteristics sug-
gest that a response bias is less likely. However, a potential
limitation was the use of a lottery versus per-individual incen-
tives that could create a response bias toward those who re-
spond for altruistic reasons.
The present study used comparative scenarios with var-
iation in diagnosis. Scenarios have been challenged in their
ability to predict an individual physician’s clinical behavior
lacking the physician-patient interaction related to pain be-
havior, patient perceptions of satisfactory care and outcome,
or other factors not included in a scenario.19,20However, Carey
and Garrett20concluded that vignette responses can be rep-
resentative of the behavior of a population of physicians. An-
other potential limitation was an order of presentation effect.
By presenting the sciatica case second, physicians may have
assumed their management should differ.
AMA membership(21% female, medianage=45
More than a decade after promulgation of evidence-based
guidelines for low back pain, a majority of primary care phy-
sicians continued to be noncompliant. Sciatica dramatically
influenced clinical decision-making, increasing the extent of
noncompliance, particularly for internal medicine and family
practice. More-experienced physicians were less compliant
than their colleagues, irrespective of diagnosis.
Reasons suggested for not following practice guidelines
include lack of awareness, familiarity, self-efficacy, or outcome
expectancy, and inertia of previous practice or external barri-
ers.21In the current study, incomplete understanding of sci-
atica’s natural history, belief that early diagnostic studies and
referrals are indicated by radiculopathy, disagreement with
evidence-based recommendations, concern for litigation, or
uncertainty regarding self-efficacy for management of a poten-
tial surgical case could underlie the observed influence of sci-
atica. Future research is needed to determine the factors
influencing noncompliance before selecting effective interven-
tions to change physicians’ practice behavior.
The authors acknowledge Mohammed Mahmud for his con-
tributions to the conceptualization of the study, Santosh Verma
for statistical consultation, Marcia Chertok for her technical
assistance, and Glenn Pransky, William Shaw, and Raymond
McGorry for their reviews of earlier drafts of the manuscript.
Funding support: Partial support received from CDC (NIOSH)
Training Grant T42/CCT 122961.
1. Hart GL, Deyo RA, Cherkin DC. Physician office visits for low back pain:
frequency, clinical evaluation, and treatment patterns from a national
survey. Spine. 1995;20:11–9.
2. Deyo RA, Cherkin DC, Conrad D, Volinn E. Cost, controversy, crisis: low
back pain andhealthof the public. Annu RevPub Health. 1991;12:141–56.
3. Frymoyer JW. An overview of the incidences and costs of low back pain.
Orthop Clin North Am. 1991;22:263–71.
4. Cherkin DC, Deyo RA, Wheeler K, Ciol MA. Physician variation in di-
agnostic testing for low back pain: who you see is what you get. Arth
5. Spitzer WO, LeBlanc FE, Dupuis M. Scientific approach to the assess-
ment and management of activity-related spinal disorders. Spine.
Table2. Adjusted Odds Ratios from Multivariate Logistic Regression
Models for Noncompliance with the AHRQ Guideline for Cases 1
Case 1 (without sciatica)
Years in practicez
Occupational medicine (n=155)
General practice (n=103)
Family practice (n=196)
Emergency medicine (n=146)
Internal medicine (n=120)
Case 2 (with sciatica)
Years in practicez
0.63 to 1.53
1.01 to 1.05w
1.75 to 7.40w
0.85 to 2.21
1.30 to 3.78w
1.63 to 5.36w
0.35 to 2.21
1.00 to 1.08?
0.57 to 7.81
1.18 to 9.11?
1.03 to 8.57?
1.47 to 32.78?
zOdds ratio and 95% confidence interval for 1-year increase.
c statistic (case 1)=0.65.
c statistic (case 2)=0.69.
Webster et al., Management of Acute Low Back Pain
6. Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults: Download full-text
clinical practice guideline No. 14. AHCPR publication No. 95-0642.
Rockville, MD: Agency for Health Care Policy and Research, Public
Health Service, US Department of Health and Human Services. Decem-
7. Koes BW, van Tulder MW, Ostelo R, Burton KA, Waddell G. Clinical
guidelines for the management of LBP in primary care: an international
comparison. Spine. 2001;26:2504–14.
8. Andersson GB, Svensson HO, Oden A. The intensity of work recovery in
low back pain. Spine. 1983;8:880–4.
9. Mahmud MA, Webster BS, Courtney TK, Matz S, Tacci JA, Christiani
DC. Clinical management and the duration of disability for work-related
low back pain. J Occup Environ Med. 2000;42:1178–87.
10. Schers H, Braspenning J, Drijver R, Wensing M, Grol R. Low back pain
in general practice: reported management and reasons for not adhering
to the guidelines in The Netherlands. Br J Gen Pract. 2000;50:640–4.
11. Cherkin DC, Deyo RA, Wheeler K, Ciol MA. Physician views about
treating low back pain: results of a national survey. Spine. 1995;20:1–9.
12. Bishop PB, Wing PC. Compliance with clinical practice guidelines in
family physicians managing worker’s compensation board patients with
acute lower back pain. Spine J. 2003;3:442–50.
13. DiIorio D, Henley E, Doughty A. A survey of physician practice patterns
andadherence to acutelow
14. Directory of Physicians in the United States on CD-ROM, 1998. Chicago:
American Medical Association; 1999.
15. SPSS Inc. SPSS 11.0. Chicago: SPSS Inc.; 2002.
16. Choudhry NK, Fletcher RH, Soumerai SB. The relationship between
clinical experience and quality of health care. Ann Intern Med. 2005;
17. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail sur-
veys published in medical journals. J Clin Epidemiol. 1997;50:1129–36.
18. AMA Council on Long Range Planning and Development. Demograph-
ic Characteristics of AMA Leadership. CLRPD Report 2– I–98. Chicago:
American Medical Association; 1998.
19. Jones TV, Gerrity MS, Earp J. Written case simulations: do they predict
physicians’ behavior? J Clin Epidemiol. 1990;43:805–15.
20. Carey TS, Garrett J. Patterns of ordering diagnostic tests for patients
with acute low back pain. Ann Intern Med. 1996;125:807–14.
21. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow
clinical practice guidelines? A framework for improvement. JAMA. 1999;
back guidelines.Arch FamMed.
Case 1. A 28-year-old married auto mechanic with no prior history of back problems reports that he experienced sudden onset of
back pain while bending forward and to the side as he was picking up a tire yesterday morning. Bed rest slightly improved his pain
and he returned to work today. However, his back pain progressively increased throughout the day, and by the end of the day he was
unable to bend and had to leave work. He denies any radiation of back pain down either leg. His past medical history is
unremarkable. Physical examination reveals markedly limited forward and right lateral flexion, as well as right paraspinal
muscle spasm and tenderness but no loss of lumbar lordosis. Both straight leg raise (SLR) and Patrick’s tests are negative.
Motor, sensory, and reflex tests are normal.
Case 2. A 35-year-old machinist has had occasional low back discomfort over the last 2 years but has not sought any medical
advice. One week ago he felt excruciating pain with radiation down his left leg after pushing a heavy object at work that caused him
to miss 3 days from work. After returning to work he experienced sharp pain in his lower back area with tingling and numbness in
his left thigh, posterior calf, and lateral aspect of his left foot, mostly after prolonged standing and bending forward. He denies any
bowel or bladder dysfunction. Past medical history is negative for cancer, immunosuppression, or other systemic diseases. Your
clinical evaluation reveals decreased pinprick sensation over the posterior aspect of the left calf and lateral foot, a diminished ankle
jerk, but no motor weakness. Both SLR on the left and cross-over SLR tests are positive and limited to 451. Patrick’s test is negative.
Webster et al., Management of Acute Low Back Pain