Evaluation of a Theory-Informed Implementation Intervention for the Management of Acute Low Back Pain in General Medical Practice: The IMPLEMENT Cluster Randomised Trial Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial. Effects of Diagnostic Information, Per Se, on Patient Outcomes in Acute Radiculopathy and Low Back Pain Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Primary care physicians' use of lumbar spine imaging tests: effects of guidelines and practice pattern feedback. Effect of audit and feedback, and reminder messages on primary-care radiology referrals: a randomised trial Impact of IT-enabled intervention on MRI use for back pain. Influence of postal distribution of the Royal College of Radiologists' guidelines, together with feedback on radiological referral rates, on X-ray referrals from general practice: a randomized controlled trial. Randomized controlled trial of the effect of the Royal College of Radiologists' guidelines on general practitioners' referrals for radiographic examination. The effect of restricting the indications for lumbosacral spine radiography in patients with acute back symptoms. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society
Introduction This cluster r and omised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain ( LBP ) in general practice . Methods General practice s were r and omised to either  access to a guideline for acute LBP ( control ) or facilitated interactive workshops ( intervention ) . We measured behavioural predictors ( e.g. knowledge , attitudes and intentions ) and fear avoidance beliefs . We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner ( GP ) level : behavioural simulation ( clinical decision about vignettes ) and rates of x-ray and CT-scan ( medical administrative data ) . All those not involved in the delivery of the intervention were blinded to allocation . Results 47 practice s ( 53 GPs ) were r and omised to the control and 45 practice s ( 59 GPs ) to the intervention . The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information ; a minimum of 38 GPs were available from the intervention group , and a minimum of 40 GPs from the control group . For the behavioural constructs , although effect estimates were small , the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral . For behavioural simulation , intervention group GPs were more likely to adhere to guideline recommendations about x-ray ( OR 1.76 , 95%CI 1.01 , 3.05 ) and more likely to give advice to stay active ( OR 4.49 , 95%CI 1.90 to 10.60 ) . Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear ; rate ratio 0.87 ( 95%CI 0.68 , 1.10 ) for x-ray or CT-scan . Conclusions The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence -based guideline , but it did not result in statistically significant changes in actual behaviour . Trial Registration Australian New Zeal and Clinical Trials Registry OBJECTIVE : The effect of clinical guidelines on re source utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied . We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain . DESIGN : Physician groups were r and omized to receive guideline education and individual feedback , supporting patient education material s , both , or neither . The impact on guideline adherence and re source utilization was evaluated during the 12-month period before and after implementation . PARTICIPANTS : Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practice s. INTERVENTIONS : Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders . The patient education component included written and videotaped material s on the care of low back pain . MAIN RESULTS : The clinician intervention was associated with an absolute increase in guideline -consistent behavior of 5.4 % in the intervention group versus a decline of 2.7 % in the control group ( P=.04 ) . The patient education intervention produced no significant change in guideline -consistent behavior , but was poorly adopted . Patient characteristics including duration of pain , prior history of low back pain , and number of visits during the illness episode were strong predictors of service utilization and guideline -consistent behavior . CONCLUSIONS : Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline -consistent behavior . Patient education material s did not enhance guideline effectiveness . Implementation barriers could limit the utility of this approach in usual care setting BACKGROUND The Royal College of General Practitioners ( RCGP ) has produced guidelines for the management of acute low back pain in primary care . AIM To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners ( GPs ) . DESIGN OF STUDY Group r and omised controlled trial , using the health centre as the unit of r and omisation . SETTING Primary care teams in north-west Engl and . METHOD Twenty-four health centres were r and omly allocated to an intervention or control arm . Practice s in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain , as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms . RESULTS Twenty-four centres were r and omised . Two thous and , one hundred and eighty-seven eligible patients presented with acute low back pain during the study period : 1049 in the intervention group and 1138 in the control group . There were no significant differences between study groups in the proportion of patients who were referred for X-ray , issued with a sickness certificate , prescribed opioids or muscle relaxants , or who were referred to secondary care , but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit ( difference in proportion = 12.2 % , 95 % confidence interval [ CI ] = 2.8 % to 21.6 % ) . CONCLUSION The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs . An increase in referral to physiotherapy or educational programmes followed the provision of a triage service BACKGROUND AND PURPOSE : We conducted a prospect i ve r and omized study of patients with acute low back pain and /or radiculopathy to assess the effect of knowledge of diagnostic findings on clinical outcome . The practice of ordering spinal imaging , perhaps unintentionally , includes a large number of patients for whom the imaging test is performed for purpose s of reassurance or because of patient expectations . If this rationale is valid , one would expect to see a measurable effect from diagnostic information , per se . MATERIAL S AND METHODS : A total of 246 patients with acute ( <3 weeks ) low back pain ( LBP ) and /or radiculopathy ( 150 LBP and 96 radiculopathy patients ) were recruited . Patients were r and omized using a stratified block design with equal allocation to either the unblinded group ( MR imaging results provided within 48 hours ) or the blinded group ( both patient and physician blinded to MR imaging results . ) After the initial MR imaging , patients followed 6 weeks of conservative management .  Rol and function , visual pain analog , absenteeism , Short Form (SF)-36 Health Status Survey , self-efficacy scores , and Fear Avoidance Question naire were completed at presentation ; 2 , 4 , 6 , and 8 weeks ; and 6 , 12 , and 24 months . Improvement of Rol and score by 50 % or more and patient satisfaction assessed by Cherkin symptom satisfaction measure were considered a positive outcome . RESULTS : Clinical outcome at 6 weeks was similar for unblinded and blinded patients . Self-efficacy , fear avoidance beliefs , and the SF-36 subscales were similar over time for blinded and unblinded patients , except for the general health subscale on the SF-36 . General health of the blinded group improved more than for the unblinded group ( P = .008 ) . CONCLUSIONS : Patient knowledge of imaging findings do not alter outcome and are associated with a lesser sense of well-being PURPOSE To prospect ively determine in patients with acute low back pain ( LBP ) or radiculopathy , the magnetic resonance ( MR ) imaging findings , prognostic role of these findings , and effect of diagnostic information on outcome . MATERIAL S AND METHODS Institutional review board approval and informed consent were obtained . This study was HIPAA compliant . A total of 246 patients with acute-onset LBP or radiculopathy were r and omized to either the early information arm of the study , with MR results provided within 48 hours , or the second arm of the study , where both patients and physicians were blinded to MR results , unless this information was critical to patient care . Patients underwent 6 weeks of conservative care . Rol and function scoring , visual pain analog , Short Form 36 health status survey , self-efficacy scoring , and a fear avoidance question naire were completed at presentation ; at 2- , 4- , 6- , and 8-week follow-up ; and at 6- , 12- , and 24-month follow-up . A second MR imaging examination was performed at 6-week follow-up . Multivariate logistic regression analysis was used to determine which imaging and nonimaging variables can be used to predict improvement in Rol and function and patient satisfaction . The chi(2 ) test and repeated- measures analysis of variance were used to compare outcome of blinded and unblinded patients . RESULTS Herniation was identified in 60 % ( n = 147 ) of patients at the initial examination . The prevalence of herniations in patients with LBP ( 57 % ) ( n = 85 ) and those with radiculopathy ( 65 % ) ( n = 62 ) were similar ( P = .217 ) , although patients with radiculopathy were more likely to have stenosis and nerve root compression ( P < .006 ) . There was no relationship between herniation type , size , and behavior over time with outcome . An improvement of 50 % or more in Rol and function score at 6-week follow-up occurred 2.7 times as often among patients with a herniation at baseline ( P = .003 ) . Improvement at 6-week follow-up was similar in unblinded ( 60 % ) ( n = 55 ) and blinded ( 67 % ) ( n = 57 ) patients ( P = .397 ) . Self-efficacy , fear avoidance beliefs , and the Short Form 36 subscales were similar for blinded and unblinded patients . CONCLUSION In typical patients with LBP or radiculopathy , MR imaging does not appear to have measurable value in terms of planning conservative care . Patient knowledge of imaging findings does not alter outcome and is associated with a lesser sense of well-being OBJECTIVE To reduce variability in primary care physicians ' use of procedures for imaging the lumbar spine . DESIGN Controlled intervention using clinical practice guideline and practice pattern feedback . STUDY SAMPLE Sixty-seven internists and 28 family practitioners in a large , group-model HMO . MEASUREMENTS AND MAIN RESULTS Intervention group physicians received the clinical practice guideline for low back pain , followed after 4 months by three bimonthly feedback reports on their current use rates for lumber spine x-rays and computed tomography and magnetic resonance imaging scans of the lumbar spine . Control group physicians received neither the guideline nor the feedback reports . Automated radiology utilization data were used to compare intervention and control group physicians ' changes in use rates and variability in use rates over the course of the study period . Neither the guideline alone nor the guideline plus feedback was associated with a significant decrease in use rates or in the variability in use rates for the lumbar spine imaging procedures under study . CONCLUSIONS Clinical practice guidelines and practice pattern feedback fail to achieve their goals when features of the practice setting and patient expectations and behavior are not identified and addressed BACKGROUND Radiological tests are often used by general practitioners ( GPs ) . These tests can be overused and contribute little to clinical management . We aim ed to assess two methods of reducing GP requests for radiological tests in accordance with the UK Royal College of Radiologists ' guidelines on lumbar spine and knee radiographs . METHODS We assessed audit and feedback , and educational reminder messages in six radiology departments and 244 general practice s that they served . The study was a before- and -after , pragmatic , cluster r and omised controlled trial with a 232 factorial design . A r and om subset of GP patients ' records were examined for concordance with the guidelines . The main outcome measure was number of radiograph requests per 1000 patients per year . Analysis was by intention to treat . FINDINGS The effect of  educational reminder messages  ( ie , the change in request rate after intervention ) was an absolute change of -1.53 ( 95 % CI -2.5 to -0.57 ) for lumbar spine and of -1.61 ( -2.6 to -0.62 ) for knee radiographs , both relative reductions of about 20 % . The effect of audit and feedback  was an absolute change of -0.07 ( -1.3 to 0.9 ) for lumbar spine of 0.04 ( -0.95 to 1.03 ) for knee radiograph requests , both relative reductions of about 1 % . Concordance between groups did not differ significantly . INTERPRETATION 6-monthly feedback of audit data is ineffective but the routine attachment of educational reminder messages to radiographs is effective and does not affect quality of referrals . Any department of radiology that h and les referrals from primary care could deliver this intervention to good effect BACKGROUND The purpose of this study was to examine the impact of a multifaceted , clinical decision support (CDS)-enabled intervention on magnetic resonance imaging ( MRI ) use in adult primary care patients with low back pain . METHODS After a baseline observation period , we implemented a CDS targeting lumbar-spine MRI use in primary care patients with low back pain through our computerized physician order entry , as well as 2 accountability tools : m and atory peer-to-peer consultation when test utility was uncertain and quarterly practice pattern variation reports to providers . Our primary outcome measure was rate of lumbar-spine MRI use . Secondary measures included utilization of MRI of any body part , comparing it with that of a concurrent national comparison , as well as proportion of lumbar-spine MRI performed in the study cohort that was adherent to evidence -based guideline . Chi-squared , t-tests , and logistic regression were used to assess pre- and postintervention differences . RESULTS In the study cohort preintervention , 5.3 % of low back pain-related primary care visits result ed in lumbar-spine MRI , compared with 3.7 % of visits postintervention ( P < .0001 , adjusted odds ratio 0.68 ) . There was a 30.8 % relative decrease ( 6.5 % vs 4.5 % , P < .0001 , adjusted odds ratio 0.67 ) in the use of MRI of any body part by the primary care providers in the study cohort . This difference was not detected in the control cohort ( 5.6 % vs 5.3 % , P = .712 ) . In the study cohort , adherence to evidence -based guideline in the use of lumbar-spine MRI increased from 78 % to 96 % ( P = .0002 ) . CONCLUSIONS CDS and associated accountability tools may reduce potentially inappropriate imaging in patients with low back pain BACKGROUND The Royal College of Radiologists ( RCR ) have produced regularly up date d guidelines on radiological referrals since 1990 . A small study in 1992 showed postal distribution of guidelines reduced general practitioners ' referrals over the subsequent 9 weeks . However there have been no r and omized trials of the longer term effects of radiological guidelines and feedback on referral rates on X-ray requests from primary care . OBJECTIVES To see if the introduction of radiological guidelines into general practice s together with feedback on referral rates reduces the number of GP radiological requests over one year ; and to explore GPs'attitudes to the guidelines . METHODS Sixty-nine practice s referring patients to St George 's Healthcare Trust were r and omly allocated to intervention or control groups . In February 1995 a GP version of the RCR guidelines was sent to each GP in the 33 practice s in the intervention group . After 9 months intervention , practice s were sent revised guidelines with individual feedback on the number of examinations requested in the past 6 months . The total number of requests per practice was compared for the year before and the year after the introduction of the guidelines . Control practice s were sent the guidelines at the end of the study . All doctors were sent a question naire about the guidelines . RESULTS A total of 43 778 radiological requests were made during the two years 1994 - 1996 . In practice s receiving the guidelines there was a 20 % reduction in requests for spinal examinations compared with control practice s ( P < 0.05 ) . This corresponded to the effect reported by GPs . There was also a 10 % difference between the groups in the total number of requests made , but due to wide inter practice variation in referral rates this failed to reach statistical significance . CONCLUSIONS Introduction of radiological guidelines together with feedback on referral rates was effective in reducing the number of requests for spinal examinations over one year . Wider use of GP-orientated guidelines with regular updating and feedback might save costs and reduce unnecessary irradiation of patients BACKGROUND The Royal College of Radiologists ' guidelines aim to encourage more appropriate use of diagnostic radiology and so reduce the use of clinical ly unhelpful x-ray examinations . AIM The object of this study was to conduct a r and omized controlled trial of the introduction of the guidelines into general practice . METHOD A total of 62 practice s ( 170 general practitioners ) referring patients to St George 's Hospital , London for diagnostic radiology were r and omly allocated into two groups . Guidelines were sent to the 30 practice s in the intervention group . Radiological referral patterns were compared in both groups before and after the introduction of guidelines . RESULTS Practice s which had received guidelines requested significantly fewer examinations of the spine , and made a significantly higher proportion of requests which conformed to the guidelines compared with practice s which had not received the guidelines . There were no significant differences in the proportion of forms giving physical findings or in the proportion of positive findings at radiology . CONCLUSION Introduction of guidelines can influence general practitioners ' radiological referrals in the short term . Wider use of guidelines might help to reduce unnecessary irradiation of patients A prospect i ve study was performed to evaluate the effect of using a special requisition form on the utilization of lumbosacral spine radiography for patients presenting in the emergency room with acute lower back complaints . Over a 1-year period , emergency room house officers were encouraged to complete a special form that listed only three acceptable indications for lumbosacral spine radiographs : history of trauma , evidence of focal neurologic abnormality , and " other . " Neurologic abnormalities included hypesthesia , hyperesthesia or anesthesia of lumbar or sacral dermatomes , weakness or hyporeflexia of the lower extremities , and bladder or bowel incontinence . If the indication " other " was chosen , radiographs were done only if the form contained both a one- to two-sentence history and the signed approval of a supervising attending physician . The number and results of lumbosacral spine examinations were compared with those from the previous year , which served as a control . In the control year 1443 examinations were performed , and in the experimental year only 759 were done ( a decrease of 47 % ) . The percentage of patients with vertebral fractures increased from 5.1 % to 5.8 % in the experimental year if only the detection of new fractures was considered positive , and from 9.1 % to 13.4 % if the detection of fractures of all ages was regarded as significant . The use of the special requisition form appears to be a simple and effective means of reducing unnecessary  lumbosacral radiography in the emergency room setting Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . However , up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode , and 1 in 5 report substantial limitations in activity ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . Children or adolescents with low back pain ; pregnant women ; and patients with low back pain from sources outside the back ( nonspinal low back pain ) , fibromyalgia or other myofascial pain syndromes , and thoracic or cervical back pain are not included . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain Recommendation 1 : Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy or spinal stenosis , or back pain potentially associated with another specific spinal cause . The history should include assessment of psychosocial risk factors , which predict risk for chronic disabling back pain ( strong recommendation , moderate- quality evidence ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied
BACKGROUND Rates of imaging for low-back pain are high and are associated with increased health care costs and radiation exposure as well as potentially poorer patient outcomes .
We conducted a systematic review to investigate the effectiveness of interventions aim ed at reducing the use of imaging for low-back pain .