Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: A systematic review and meta-synthesis of qualitative studies

Dr Susan Slade1,2

11Dept of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia, 22Dept.of Clinical Epidemiology, Cabrini Institute, Melbourne, Australia


Low back pain is the highest ranked condition contributing to years lived with disabilityand associated with significant cost. Despite consistent evidence-based recommendations primary care management remains suboptimal.


To summarise what primary care clinicians believe about clinical practice guidelines for low back pain.


Systematic review methods conformed to Cochrane guidelines and PRISMA and ENTREQ Checklist.  Inclusion criteria: English-language studies of primary care clinicians and qualitative methods for data collection and analysis. Eight electronic databases were searched until July 2014.


From a yield of 1880 titles, 17 papers, with a total of 705 participants, fulfilled inclusion criteria. Studies were conducted in UK, Canada, USA, Netherlands, Germany, Israel, New Zealand and Norway and included general practitioners, physical therapists, chiropractors, osteopaths and occupational therapists.Many studies failed to report  key study components, such as researcher influence, data saturation and explicit data analysis steps, to allow full assessment of trustworthiness. We identified three key themes: (1) beliefs/perceptions about guidelines; (2) maintaining the patient-clinician relationship; (3) barriers to guideline adherence.

Significance to allied health

Clinicians believe that: guidelines are categorical, prescriptive and constraining; popular clinical practices supersede the guidelines; imaging referrals can be used to manage consultations. Guidelines are perceived as at odds with individual patient needs and practitioner preferences, and the complex nature of persistent low back pain.  Clinicians’ perceptions reflect lack of content knowledge and understanding of guidelines development. We recommend clinician engagement in guideline development; empowering clinicians with communication skills and concise guideline summaries; and discipline-specific implementation strategies.


low back pain, clinical practice guidelines, qualitative, primary care