Management of Low Back Pain in Primary Health-Care Settings | JMDH – Dove Medical Press


Low back pain (LBP) is one of the most common health problems and is considered the second most frequent cause for seeking medical advice, 1 and the leading cause of disability plus work absenteeism around the world. one It is also a significant economic burden on individuals in addition to communities. 2 In the Kingdom of Saudi Arabia, LBP is a common condition with a prevalence ranging between 53. 2% and 79. 2%. 3

Because of the high prevalence associated with LBP and even the burdens it creates, many evidence-based guidelines have been established to diagnose and effectively treat patients with LBP. 1 Although most cases of acute LBP are self-limiting, LBP can be an indication of more serious conditions, such as malignancy, spinal fractures, infections, cauda equina syndrome, together with aortic aneurysms. 1 Most regarding the accepted contemporary guidelines focus upon the determination of the presence of red flags (RFs) of LBP. 1

RFs are “signs and symptoms that raise suspicion involving serious pathology”. 4 , 5 RFs reported during a medical history or discovered during physical examination are usually associated with a higher prevalence connected with serious conditions that may be related to back pain. 6 Therefore , knowing these RFs helps early diagnosis and proper management with serious problems. 7 Identifying one or more of these types of RFs should be followed by a proper investigation 6 because neglecting these kinds of RFs can lead to serious consequences and more morbidities and higher rates for mortality. 1 , 8

Although some RFs have been criticized due to the fact they usually are not supported by empirical evidence for some circumstances, RFs remain the best tool with regard to clinical screening for more serious conditions. 4 A study conducted among 1172 patients with LBP found that only 0. 9% had severe conditions, whereas 80. 4% of all these patients had at least one RF, including using corticosteroids, being over 70 years of age, and additionally having experienced trauma. 9 Moreover, studies showed that ignoring LBP management guidelines could increase mortality from significant spinal pathologies. 10 Primary care physicians play an important role in the analysis and administration of LBP because they are the first physicians to possess contact with individuals and, thus, they can help reduce an unnecessary workload for the particular specialized services. 11

The southwest region of Saudi Arabia is a heavily populated area, and typically the health care there is stepping forward but not as in the capital not to mention other industrial cities. This region has its own health issues that are distinctive from other regions within Saudi Arabia. Low back pain and also TB will be two main areas in order to explore as well as modify nowadays to provide the health care provider along with valid data to modify healthcare accordingly to be able to serve our community. 12 This particular should include the patterns about awareness among all doctor categories, wrong or defensive practices like un-necessary investigations or referrals, points in strength for you to consolidate, and management protocols for LBP in this over-populated location.

Few studies have investigated the perceptions and practices of doctors regarding RFs in patient with LBP in Saudi Arabia. 7 , 11 However, no studies have been carried out in southwest Saudi Persia, the intended area plus population from the current study. Furthermore, in compare to some other regions inside Saudi Arabia, the primary health care within the study area still mostly continued to help be covered by a non-family physician with different levels of training in addition to experiences plus is still missing this complimentary part of nurse practitioners and physician assistance as a frontline regarding screening in a common clinical presentation like back discomfort. This different health care setting needs to be investigated to ensure adequate levels associated with RF awareness and limits un-necessary diagnostic imaging and even higher center referrals, we mainly aim to assess primary healthcare physicians’ awareness of together with practices intended for RFs throughout patients together with LBP and additionally identify often the variables associated with a high level of knowledge not to mention practice including however, not limited to level of training, degree and experience. This way, we can pin-point the areas regarding strength and also weakness in the whole process as well as use your awareness of LBP RF in order to guide us to this particular. The results involving this work in Jazan could lead to future interventions from the exact health authorities to address these kind of areas of weakness.

Materials and Methods

Study Design, Setting, and Participants

An observational cross-sectional study was performed in the Jazan Region, around southwest Saudi Arabia, on June 2021. The target population from the study was primary care medical professionals working in the Jazan place. Five-hundred medical doctors work under the umbrella of the particular Ministry connected with Health, Jazan Health Directorate. Inclusion criteria involved all physicians working in primary health treatment include general physicians plus family medicine doctors, who signed typically the informed consent form. Exclusion criteria involved doctors working for less than six months within the selected health institution.

Health-care solutions in Saudi Arabia, which includes preventive in addition to curative services, are provided by different governmental and private sectors. However, most health-care services during the country are provided simply by the Ministry of Health. Saudi sufferers suffering from LBP may benefit from the freely available health-care providers that happen to be provided for primary health-care centres (PHCs), hospitals, and even specialized centres. Nonetheless, this main context of often the study was PHCs since they are the main provider of health-care services to get patients affected with the targeted condition.

Sampling Procedure

The particular initial sample size proposed for this specific study was calculated to be able to be 218 physicians; this kind of calculation has been based about the prevalence of knowledge of 50% (because no previous research have already been conducted) and a 95% confidence interval, with an error rate of lower than 5% along with a population size of 500. The final sample size was increased by 20% to account for nonresponders, leading for you to a final test size with 261 health professionals. All provinces in the Jazan region were included in the study. The list for PHC professionals in each province has been obtained from your Health Affairs Directorate through Jazan. We used the stratified random sampling technique with proportional allocation to select the PHC physicians.

Data Collection together with Study Instrument

Data had been collected electronically through a new self-reported questionnaire. The questionnaire was prepared in English as almost all physicians have been able to help communicate fluently in British, read, spoken, and written. The developed questionnaire consisted of three parts. Part one consisted of participants’ demographic factors, which include their age, gender, nationality, specialty and additionally experience, not to mention the number of patients using back soreness they encounter per month. Part two was meant to assess the awareness about participants about RFs regarding three important conditions in patients having LBP, like cauda equina syndrome, tumors/infections, and trauma. All questions were prepared to become answered by using “Yes” or “No”, and also “Yes” had been correct. Furthermore, part three was prepared to assess the exact practice in participants pertaining to referring to the hospital as well as asking meant for lab tests, CT scans, and MRI scans. The validity and reliability of the created questionnaire were being tested via a pilot study on a sample from 28 to test its clarity, suitability, and the time needed to complete the particular questionnaire. Typically the questions ended up reviewed by simply three experts with expertise in spine specialty to assess typically the face quality from the instrument. Finally, this reliability of the tool was tested by estimating the Cronbach’s alpha coefficient. The estimated coefficient associated with items assessing knowledge plus practice was initially 0. seventy, indicating an acceptable internal consistency of often the measurement tool.

Data Analysis

The data was analysed using your Statistical Package for the Social Sciences (SPSS) version 20, (Chicago, IL, USA). Descriptive (frequency in addition to percentage) and even inferential statistics were used. The total score expertise regarding RFs seemed to be computed using the questions about RF knowledge. Correct answers were definitely assigned 10 marks. Means with their standard deviation were calculated and used to describe the total knowledge. Categorical variables happen to be described as frequency and percentage, as well as the chi-squared test was initially used to test the associations. To evaluate the differences in the demographics and professional backgrounds, all of us compared the exact means understanding scores using the Student’s t -test and one-way ANOVA, respectively. A logistic regression was basically used in order to estimate odds ratios through their 95% CI for that variables associated with physicians’ information. All statistical tests was 2-sided, and also a p-value regarding < 0. 05 was first used to be able to indicate record significance.

Research Ethics

This ethical approval to conduct the project was granted by the Jazan Health Ethics Committee, utilizing approval number REC2040 in September 8, 2020. All of us conducted that study following the ethical guidelines of the Helsinki Declaration and the local recommendations from the National Committee involving Bioethics, Saudi Arabia. Physicians participating in the following study ended up being informed concerning the purpose of the study and signed a written consent for you to participate before data collection. All collected data are kept confidential and utilized for only the purpose connected with research. Also, the questionnaires did not include participants’ names, mobile phone numbers, or any additional methods of identification. All the participants were given the particular right to continue or withdraw at any time from your study.


The overall response rate was 96. 1%, 251 of the planned sample with 261. Table 1 illustrates the demographic information, occupational profiles, together with knowledge scores of RF among medical practitioners participating in the study. Men represented 56% from the participants; 49. 4% of the participants were aged 35–44 years; and 76. 9% were non-Saudi. We all found that 49. 4% of individuals were common practitioners, 25. 5% had been specialists, and additionally 23. 1% were residents. Forty-nine percent from the individuals had encounter of 1–9 years. In addition, 33. 1% of members indicated they deal with the help of more than 30 patients with back pain per month. Stand 1 furthermore showed that will the overall mean score of RF knowledge among the physicians was in fact 82. 33 ± 36. 3, along with 95% CI (77. 7–86. 9). There was no statistically significant within knowledge rating between women and men (85. 5 ± thirty-three. 6) not to mention (79. 9 ± 38. 2) correspondingly (p = 0. 230). Neither designed for Consultants/specialists and also physicians with experience of more than 10 years and less than 10 many years 90. 0 ± 28. 5 as well as 85. seven ± 34. 3 respectively, (p > 0. 05). Although Doctors who see lower than 15 patients inside the clinic had large scores (89. 0 ± 30. 6) compared together with those who observe a lot more than fifteen patients per month (78. 4 ± 38. 8) (p sama dengan 0. 020).

Table 1 Demographic, Professional Profile, and Knowledge Scores of RFs Among Physicians Involved in the Study

Table 2 demonstrates typically the Physician’s Knowledge regarding this signs of red flags. Table 1 shows that the extent of understanding of red flags of severe low back again from the main medical care physicians was mainly pronounced throughout history for trauma (98. 4%) accompanied by a history of cancer (98. 0%), Bladder dysfunction (97. 4%), Neurologic deficit within the lower extremity (93. 8%), while the lowest appreciated red flag about acute low back pain was younger than twenty years (53. 3%). There was clearly no significant difference in physicians’ responses according to job category except just for minor stress in elderly patients plus age greater than 50 years (p-value < 0. 05 for the purpose of both). According to Figure a single , we all found of which 88. 1% of contributors had good awareness in the RFs for cauda equina syndrome, whereas 92. 7% did for tumors/infections and 86. 2% do for injury.

Table two Physicians’ Understanding Regarding the Signs and Symptoms of Red Flags

Figure 1 Main health attention physician’s consciousness of critical LBP red flags domains.

The overall percentage from referring patients with back again pain is 10. 6%, and often the rate of referral will be highest amongst general practitioners, then residents, specialists, in addition to consultants. General practitioners and even residents are more likely to refer patients using nonspecific again pain than specialists together with consultants. Fortunately, more compared to 95% associated with participants would refer individuals to the hospital if they noticed the presence of RFs. Specialists and additionally consultants recommend cases having osteoarthritis at a significantly lower rate than basic practitioners not to mention residents (p = 0. 001) ( Table 3 ).

Desk 3 Primary Health Care Physicians’ Practices Concerning the Red-colored Flags

Additionally, 93. 6% and 90. 8% regarding physicians might ask with respect to laboratory tests in the case of tuberculosis (TB) infection or if suspecting there were rheumatological diseases, correspondingly, with simply no factor between different types of consultants. Furthermore, many of us found the fact that 94. 5% of people would ask for an Xray when acute backside pain persists for more than a couple of weeks by using RFs; 65. 1% would certainly ask when it comes to an Xray when serious back discomfort persists with regards to more as compared to 2 weeks without RFs; and 28% would inquire for a good Xray whenever acute rear pain continues for less than 2 weeks without RF signs. General practitioners and also residents have been significantly more likely to request for a great Xray, even for signs and symptoms that persist for much less than 14 days without RFs (p = 0. 006) ( Table two ).

Considering computed tomography (CT), we found that most participants would likely ask for COMPUTERTOMOGRAFIE in cases involving metastatic disease (92. 7%), extra-spinal pathology (87. 6%), plus a cauda equina lesion (82. 1%). General practitioners were a lot more likely when compared with other physicians to question for some sort of CT scan in people with a good nerve root or spinal cord compression. Moreover, most of us found that 93. 1% of players would request magnetic resonance imaging (MRI) in cases of a cauda equina ofensa; 92. 7% would consult for one in instances of nerve root/cord data compresion; and 84. 4% will ask for one for metastatic conditions ( Stand 3 ). Often the percentage connected with physicians that will order a CT or MRI for sufferers with suspected infection really are 46. 8% and 42. 2%, respectively. The general percentage with referrals for patients through nonspecific LBP is considered high (57. 8%).

A logistic regression analysis was executed utilizing the dependent variable degree of PHC physicians’ expertise that is usually categorized into two categories: high and low levels of know-how. The analysis revealed the female gender was associated utilizing a high level about knowledge (OR = 2 . 2, 95% CI sama dengan 2. 3–4. 8, P < 0. 05). The number of patients with the help of back problems seen each month (fewer in comparison with 15) was also associated with an increased stage of experience (OR = 2. only two, 95% CI = 1 . 1–4. five, P < 0. 05). Being your consultant/specialist as well as older were being not related to higher awareness ( p -value > 0. 05 for all) ( Table four ).

Table some Factors Associated with a High Level of RF Knowledge Using the Logistic Regression Model


Identification of really serious pathological situations among affected individuals with LBP is some high-priority wellness issue worldwide. Reasonable tools should guide physicians to help detect and triage those with potentially considerable conditions one of the large pool of people with low back suffering. It is definitely important to avoid providing patients along with false reassurance when they have critical ailments and exaggerating simple ones. 4 This balance requires a certain degree of education and experience among the treating physicians, plus ideally, a fabulous RF-based assessment method together with reasonable sensitivity and specificity would assist achieve this goal.

Acute LBP bouts are usually nonspecific and tend to be self-limiting with time. History in addition to physical examination alone can provide reliable clues in order to detect major etiologies in LBP. 6 This specific concept constituted the basis on which various diagnostic roadmaps were designed. Because the skills and the levels of encounter determine the outcome of individual care, your authors focused on the evaluation of health-care providers’ awareness of different levels of RFs, which highlight substantial spine pathologies such as cancer, bacterial infections, and fractures.

In this study, we found that the physician’s overall mean score from RF knowledge was 82. 33 ± 36. a few, which indicates a good amount of recognition about RFs in patients with LBP in compare to various other studies done in Saudi Arabia. one , 7 Moreover, 94. 5% ended up aware these people should order X-rays to find patients who were symptomatic to get more than 2 weeks despite being dedicated to be able to conservative medical treatment. The study also demonstrated a comparable high attention level regarding the proper radiological investigations in the event of thought cauda equina syndrome, metastatic diseases, radiculopathy, and extraspinal pathologies.

A study conducted around Riyadh, central region of Saudi Persia, to measure the level associated with knowledge of PHC physicians with regards to RFs to patients using LBP, it was discovered that the majority of physicians (68%) had good understanding of RFs, including neurological deficits (72%), age (45%), and background of vertebral trauma (41%). However, just 30% could suspect most of these signs on acute situations. 1

Another study practiced in Jeddah, western spot of Saudi Arabia, during 2014 for you to assess the exact amount of practical knowledge and practice of doctors found that will among 180 physicians, bladder dysfunctions were definitely the most known RF in 83. 9%, an age of over 50 years was recognized by 77%, a history of trauma was identified by 73. 3%, and weight loss as an important RF with acute LBP was known by 68. 9%, which is lower than the level of knowledge of this research participants. Acute pain for less than 2 weeks was not recognized by most of the sample. In addition, the consultants seem to help have a higher level of knowledge than standard practitioners. 7

The southwest region regarding Saudi Arabia is  a heavily populated region, as well as the health care there is moving forward but not as in the capital and commercial cities. This kind of region offers its own well being problem that is distinctive from other regions for Saudi Arabia. 12

Due to differences through healthcare disorders and health and fitness problem involving Jazan, we will utilize the results and even conclusions connected with this work to consolidate areas with strength together with improves areas with lower awareness, modify the supervision process to limit unnecessary referrals in order to higher centers and improve the diagnostic image utilization profile by offering these conclusions to local health government bodies and planning future training programs to be able to improve managing of these patients inside our over-populated region.

Considering practices to obtain RFs in patients having LBP, most people found medical professionals would relate patients when they had osteoarthritis symptoms. Also, tuberculosis is a possible cause of LBP, and additionally back pain is the particular main symptom of spine tuberculosis; typically the intensity for pain varies from constant and mild aching for you to severely disabling pain that is generally localized towards the thoracic region. 13 In our own study, 93. 6% about physicians would probably request lab tests if they suspected TB and ninety. 8% when they suspected rheumatological diseases.

Radiography may not be useful in determining the cause of LBP complaints because it can examine the particular bone. 14 , 15 Diagnostic tests such as the CT or even MRI ought to be performed in clients with a new history or perhaps who have received an exam that strongly indicates some sort of serious reason for back agony, such because cauda equina syndrome, attacks, or tumors. Early imaging is not required in persons whose sciatica is likely due to a good herniated disc or vertebrae stenosis unless significant nerve abnormalities can be identified. Early imaging is not needed because many patients will improve with conservative treatment. six , 16 , 17

Moreover, found in another research, it was basically found of which 26. 9% of medical doctors would manage cases in LBP without sciatica not to mention 4. 3% of health professionals manage circumstances of LBP with sciatica by following this Agency needed for Healthcare Research and Quality guidelines available for back soreness. However , many PHC physicians are noncompliant with this suggestions. 18 These results showed the fact that physicians in our trial had great knowledge and also awareness from RFs to have LBP, although they tend to be over-investigating subjects and making early recommendations for individuals with non-specific and short-duration low backside pain in the absence of RFs, inside of particular one of the junior doctor which may reflect your low level of experience as well as confidence which may need future interventions through the health regulators to address these places of some weakness.

Study Limitations

This study is some cross-sectional based on self-reported questionnaires, which has its limitations and potential biases, often the external generalizability of your study result is limited to help Jazan area as well as similar health care settings worldwide.

Implication for Clinical Practice

That study can be the first to assess the awareness associated with physicians at PHC configurations about RFs for LBP within the Jazan Region, Southwest Saudi Persia. This examine, demonstrate a fabulous high degree of awareness and knowledge regarding the RFs for LBP among PHC physicians, even though they have a very low threshold for referring LBP clients to the exact specialized clinics and for requesting investigations specially among junior physicians. The following kind involving attitude plus practice overwhelms spine treatment centers by unneeded consultations in addition to increases the waiting time which usually may affect patients with a serious backbone disease. Further educational programs and courses with a focus on junior doctors are needed based on this study result. To enhance their own practice to be able to identify and handle a non-specific LBP and even minimize the unnecessary together with premature referral to spinal column clinics.

We will utilize the particular results and additionally conclusions connected with this work to combine areas with strength not to mention improves locations with lower awareness, change the control process in order to limit unwanted referrals to be able to higher facilities and enhance the diagnostic image utilization user profile.


Overall, awareness for RFs in support of LBP and also referring critical patients who else present by using low rear pain is certainly good amid primary healthcare (PHC) professionals in typically the Jazan Region. Junior medical practitioners have a low threshold for you to request images. The recommendation rate suitable for nonspecific LBP is still higher, which could overwhelm spinal centers. Further educational programs relating to back serious pain management are really recommended to help ensure sufficient levels about RF understanding and limitations un-necessary analysis imaging as well as higher center referrals.


CT, Computed tomography; LBP, Low spine pain; MRI, Magnetic vibration imaging; PHCs, Primary health care centers; RF, Red flags; TB, Tuberculosis.

Ethical Approval

Your ethical authorization to carry out the task was given in the Jazan Health Integrity Committee through approval quantity REC2040. Many of us conducted this particular study following the honest guidelines of the Helsinki Announcement and this local rules from the National Committee in Bioethics, Saudi Arabia.


This research failed to receive any specific grant through funding agencies in the public, commercial, or maybe not-for-profit sectors.


The exact abstract from this paper was presented at often the Saudi Association of Neurological Surgery, SANS Conference since a poster presentation utilizing interim findings. The poster’s abstract appeared to be Published while “Poster Abstracts” in your Spine Practice Journal: [ ]. The authors report no conflicts of interest within this function.


1. Alsaleh K, Alluhaidan A, Alsaran Y, et al. Acute back painfulness: a survey of main health care physicians′ knowledge and knowledge of “red flag” signs. Saudi J Med Sci . 2016; 4(1): 12-15. doi: 10. 4103/1658-631x. 170882

3. Hoy D, March L, Brooks G, et al. The global burden of reduced back problems: estimates coming from the Global Burden of Disease 2010 study. Ann Rheum Dis . 2014; 73(6): 968–974. doi: ten. 1136/annrheumdis-2013-204428

3. Awaji M. Epidemiology of small back pain in Saudi Arabia. M Adv Med Pharm Sci . 2016; 6(4): 1–9. doi: 12. 9734/jamps/2016/24173

4. Finucane LM, Downie A, Mercer C, ainsi que al. International framework to receive red flags for possible serious spine pathologies. L Orthop Sports Phys Ther . 2020; 50(7): 350–372. doi: ten. 2519/jospt. 2020. 9971

5. Pennella D, Giagio S, Maselli F, ou al. Red flags useful to screen concerning gastrointestinal and hepatic diseases in persons with shoulder pain: an important scoping review. Musculoskeletal Care . 2022. doi: twelve. 1002/msc. 1628

6th. Atlas SJ, Deyo RA. Evaluating plus managing acute low returning pain within the primary care and attention setting. T Gen Intern Med . 2001; 16(2): 120–131. doi: 10. 1046/j. 1525-1497. 2001. 91141. x

7. Alghamdi M, Mattar The, Yamani O. Assessment expertise, attitude in addition to practice associated with red flags related to extreme low lower back pain among primary overall health care medical doctor, ministry regarding health, Jeddah 2013–2014. Int J Adv Res . 2016; 4(12): 1809–1816. doi: 10. 21474/ijar01/2586

8. Maselli F, Palladino Meters, Barbari V, Storari L, Rossettini G, Testa Mirielle. The classification value involving Red Flags inside thoracolumbar suffering: a systematic review. Disabil Rehabil . 2022; 44(8): 1190–1206. doi: 10. 1080/09638288. 2020. 1804626

nine. Henschke N, Maher CG, Refshauge KM, et ing. Prevalence connected with and testing for dangerous spinal obstacle in men and women presenting to primary treatment settings with the help of acute minimal back agony. Arthritis Rheum . 2009; 60(10): 3072–3080. doi: 15. 1002/art. 24853

12. Major-Helsloot ME, Crous LC, Grimmer-Somers K, Louw QA, Major-Helsloot ME PERSONALLY, Grimmer-Somers K. Management with LBP from primary proper care level throughout South Africa: up to standards? Afr Wellness Sci . 2014; 14(3): 698–706. doi: 10. 4314/ahs. v14i3. 28

11. Albahlal JM, Alhandi AA, Aldihan KA, et ‘s. Primary health-related physicians’ adherence to intense lower to come back pain affiliate guidelines around Riyadh, Saudi Arabia. Saudi Med N . 2018; 39(8): 838–841. doi: twelve. 15537/smj. 2018. 8. 22539

twelve. Alnaami I, Awadalla NJ, Alkhairy Michael, et approach. Prevalence and even factors connected with low back pain amongst health attention workers on southwestern Saudi Arabia. BMC Musculoskelet Disord . 2019; 20(1): 1–7. doi: 20. 1186/s12891-019-2431-5

13. Garg RK, Somvanshi DS. Spinal tuberculosis: a review. C Spinal Cord Med . 2011; 34(5): 440–454. doi: 10. 1179/2045772311Y. 0000000023

14. Van Tulder MW, Assendelft WJJ, Koes BW, Bouter LM. Spinal radiographic findings together with nonspecific very low back pain: an organized review of observational studies. Spine . 1997; 22(4): 427–434. doi: eight. 1097/00007632-199702150-00015

15. Rao D, Scuderi G, Scuderi C, ain al. The particular use for imaging during management about patients with low back pain. Is usually Clin Imaging Sci . 2018; 8(1): 30. doi: 10. 4103/jcis. JCIS

16. Mathews JA. Back pain and additionally sciatica. Rheumatology . 1988; 27(4): 331. doi: 15. 1093/rheumatology/27. 5. 331

17. Deyo RA, Bigos SJ, Maravilla KR. Analysis imaging procedures for your lumbar spine. Ann Internal Mediterranean sea . 2017; 111(11): 865–867.

18. Webster BS, Courtney TK, Huang YH, Matz S, Christiani DC. Brief statement: physicians’ initial management in acute small back anguish versus evidence-based guidelines. Influence of sciatica. J Gen Intern Med . 2005; 20(12): 1132–1135. doi: 20. 1111/j. 1525-1497. 2005. 0230. by

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