Work for Accident Compensation Corporation (ACC)
Between 1999 and 2007 I was commissioned by the
New Zealand Accident Compensation Commission (ACC) to conduct number of research projects. My colleague Bruce Arroll was also assisted in this research and is co-author on a number of the publications. Some of the later work involved other co-authors. Reports were produced for ACC for each commissioned work and the findings were also published in peer-reviewed journals.
Imaging and referrals with respect to acute and chronic low back pain
In 2001 I conducted a literature review and research to provide recommendations to ACC regarding imaging and referrals with respect to acute and chronic low back pain:
Recommendations for GPs regarding imaging with respect to low back pain: a Delphi and evidence-based study
Goodyear-Smith F, Arroll B New Zealand Family Physician, 29 (2): 97-101, 2002
Abstract
Introduction: Despite evidence-based guidelines, plain x-rays are used more extensively than recommended in low back pain, do not help diagnose simple back pain or nerve root problems and carry high false-positive risk.
Aim: To review the literature regarding GPs’ use of plain x-ray and determine expert opinion regarding use of these investigations.
Method: A literature review and modified two-round Delphi consultation was conducted with a panel of GPs and other relevant practitioners.
Results: There was consensus that most low back pain resolves, and spondylosis and disc degeneration findings are common in both symptomatic and non-symptomatic patients, hence in absence of trauma or other ‘red flags’ lumbar spine x-rays should be avoided for 4-6 weeks. X-rays are recommended where serious pathology is suspected. Opinion was mixed regarding MRI as first-line investigation. Lumbar x-rays require 30-40 times the dose of chest x-ray radiation.
Conclusion: Where there is consensus on the literature GPs should adhere to recommendations. Lack of consensus justifies GP clinical flexibility. A greater awareness by doctors and patients of radiation levels involved may diminish ordering lumbar x-rays when serious pathology is unlikely.
GP management and referral of low back pain: a Delphi and evidence-based study
Goodyear-Smith F, Arroll B. New Zealand Family Physician, 29 (2): 102-107, 2002
Abstract
Background: Numerous evidence-based guidelines on low back pain management have been produced but specific conditions for General Practitioner (GP) referral are not always specified.
Aim: Literature review and expert consultation to determine best management circumstances and timing of referral to other health practitioners.
Method: Multi-disciplinary panel underwent two-round Delphi consultation assessing their opinions and degree of agreement to evidence-based statements.
Results: Conservative treatment should include information about low back pain; reinforcement of positive expectations; education about self-management and self-responsibility, pain management and control and increase in exercise tolerance. NSAIDs, muscle relaxants and manipulation should be considered if there is no radicular pain. Referral for steroid epidural injections, TENS, acupuncture, traction and lumbar support should be avoided. Clinically severe nerve impingement requires referral to orthopedic surgeons. There was consensus that referral should occur if no improvement after 6 weeks and certainly after 12 weeks. To whom GPs should refer is not clear.
Conclusion: Where there is good evidence there is usually a consensus regarding management and referral for back pain, for example no or limited referral for acute pain. Where there is no or equivocal evidence then clinical judgement for individuals is needed. More randomised controlled trials are required to elucidate the best persons to whom GPs should refer patients with subacute or chronic back pain.
796-799, February 2025.