Paradigms of care delivery are now needed. Comment to “Routine primary care management of acute low back pain: adherence to clinical guidelines” by V. González-Urzelai et al.

Guidelines on the management of acute low back pain have been available for many years, and over the last decade there has been a broad consensus between different bodies and different countries on the need for education, reassurance, continuance of normal activities and an emphasis on the benign self-limiting nature of such attacks. It is very disappointing that such poor compliance with guidelines was discovered by this study. Although this work was carried out in Spain, there is no reason to suppose that results would be substantially different elsewhere in Europe.

One explanation of the poor compliance is alluded to by the authors—that only between 2% and 4% of consultations with primary care practitioners are related to low back pain. In recent years general practitioners have been inundated with guidelines for every conceivable condition, and there is no reason why more attention should be paid to those relating to back pain than to any other condition.

It is clear that better mechanisms for the delivery of care based on the best evidence need further evaluation. The message to primary care physicians must be consistent, and special pleading for particular treatments by interest groups should be reduced. The primary care physician is also a member of the public, and the study in Australia has demonstrated that public perceptions can be dramatically changed. Recipients of educational material are always more receptive when they perceive a problem. In Spain, access to secondary care was thought to be unsatisfactory and, in managing this problem, better implementation of guidelines may be achievable. Finally, it may be questioned whether a primary care physician is the best practitioner to see first-time attenders with back pain. Research in secondary care has demonstrated that nurse practitioners or specialist physiotherapists can deliver evidence-based management programmes very successfully.

The study has demonstrated that, after almost a decade, conventional attempts to deliver guideline-based management in primary care have not succeeded.