Because back pain is more often recurrent than acute and self-limiting, its management can be complex and costly (10). Up to 25% of patients with back pain seek help from a health care provider, with nearly three-quarters of these patients presenting to either a physician or a chiropractor. In the case of chronic LBP, 91% of patients consult a physician and 25% see a chiropractor (5). Primary care physicians undertake the initial evaluation in 65% of LBP cases and often ultimately become the sole provider for these patients (3,11). Most patients tend to visit more than one provider (12), and between 10% and 50% of patients receive physiotherapy (13,14).

Clinical practice guidelines are systematically developed statements that assist practitioners and patients in choosing appropriate interventions for specific clinical situations (15). Most LBP guidelines emphasize the importance of considering psychosocial risk factors for developing chronic pain, reassuring patients that their condition is not serious and encouraging them to remain active within the limits of their pain (Table 1) (16).

Despite the availability of guidelines, patterns of practice with respect to LBP vary widely and are notoriously resistant to change (11). Health care providers often rely on shared beliefs and personal opinion rather than research evidence to make treatment decisions (17,18). This ignorance of or unwillingness to follow evidence-based practice recommendations is responsible for what has become popularly known as the know-do gap – the gap between what is known and what is done in practice (19). The know-do gap is particularly apparent in conditions in which treatments are controversial and no single therapy is universally effective (13). The pervasive use of ineffective treatments for LBP is considered a likely contributor to its high prevalence (20).

The objective of the present report was to examine the available published literature pertaining to knowledge gaps in the management of LBP in the primary care setting. This work was conducted as part of the Alberta Ambassador Program (21–23), which aimed to construct an Alberta guideline that aligns guidance on the prevention, diagnosis and treatment of acute, subacute and chronic LBP across multiple primary care disciplines. The review results will be used to prepare a scoping survey for identifying knowledge gaps in LBP management among Alberta’s primary care practitioners, and to identify potential barriers to implementing and disseminating a multidisciplinary guideline on the management of LBP.

Twelve of the 14 included studies used self-reported answers to questionnaires, which do not necessarily reflect what respondents actually do in practice and may overestimate their concordance with published guidelines (27,31). In addition, large-scale practitioner surveys are susceptible to response bias and the reliability of participant responses is not assured (41). On the other hand, while data from the two studies (11,25) that used chart review may be more uniform and reliable than those derived from surveys, the results are less generalizable. In addition, these studies are limited by the potential effects of regional norms, and their reliance on the accuracy and completeness of medical records for the veracity of the retrospectively derived data (40). Despite the potential for overestimation of compliance in the data set, high rates of noncompliance were still observed in some areas of practice. Thus, a know-do gap clearly exists among primary care practitioners in many countries with respect to the diagnosis and management of LBP. The assessment of red flag conditions and use of diagnostic imaging among physicians was less than ideal, particularly for patients with chronic LBP or sciatica. In addition, a significant proportion of physicians and physiotherapists made inappropriate recommendations regarding sick leave and continuing activity. Treatments supported by guidelines, such as spinal manipulation, were underused, whereas ineffective treatments (eg, acupuncture, spinal mobilization and traction) were overused.

Practitioner groups are often more receptive to a guideline when they are aware of shortcomings in the care that they provide (42) and, ironically, physicians with a special interest in LBP are probably the group in greatest need of guidance (43). The present review provided a starting point for the Alberta Ambassador Program to quantify and increase awareness of knowledge gaps in the local primary care milieu. Once the current state of practice and knowledge in LBP management is ascertained, barriers to change can be identified. The dissemination strategy for a newly constructed, locally produced multidisciplinary guideline on LBP management can then be developed to ensure that the know-do gaps inherent within each primary practice discipline are specifically targeted.

While the present review was useful for ascertaining knowledge gaps and targeting guideline dissemination, it also demonstrated that guidelines have not been effective in ensuring that patients receive recommended diagnostic and treatment interventions. One study (31) that measured overall compliance in a sample of 87 family physicians found that 68% adhered to guidelines on LBP, but only 6% achieved a compliance level of greater than 90%. Another study (34) actually found no significant difference in practice behaviour between practitioners who were familiar with guidelines and those who were not, but what this suggests about the utility of guidelines is unclear. Even when practitioners are conversant with current guideline recommendations, various factors can affect their degree of compliance with these directives. In addition, a lack of agreement among health care practitioners who manage patients with LBP can hinder the propagation of evidence-based guideline recommendations, resulting in patients receiving conflicting advice about treatments. This situation is exacerbated by the lack of definitive evidence for some diagnostic tests and LBP treatments, which engenders confusion and continued disagreement regarding what constitutes optimal patient care.

Because the included studies detailed the true knowledge gaps among health care professionals, it is unclear whether the reported guideline noncompliance was related to the strategies used to implement the guidelines, the guidelines themselves, the systemic deficiencies within the health care systems or the intangible behavioural factors that affect practice patterns. A number of included studies used the same pool of international LBP guidelines to benchmark practitioner responses. This indicates not only a commonality among the studies in terms of what they were measuring, but also the transferability of guidelines across international settings. The corollary of this is the potential limitation of studies (33,36) that expected survey respondents to be familiar with guidelines that were not locally produced. Because few of the studies actually assessed whether the participants were familiar with the guidelines their practices were being benchmarked against, it was also unclear to what extent ignorance and deliberate noncompliance factored in the observed results.