Table 4 Comments subtracted using the metaplan technique from group discussions of GPs.

Guideline in general

■ Patients need to be taken serious

■ Guideline downplays patients' pain

Communication

■ Difficulties conveying the non-biomechanic diagnosis

■ Mentioning the guideline approved by university increases credibility

■ Difficulties "selling" psychotherapy for LBP

Physical activity

■ Is easier to promote in younger people

■ Is mainly attractive for women

■ It is hard to motivate elder man

■ It is hard to motivate and give reasons for physical activity to physically hard working patients

Physiotherapy

■ Patient are highly satisfied with physical therapy

■ Knowledge deficits about what physical therapist can do

■ Suspicion that PT change prescription for physical therapy into massage

Imaging

■ General agreement on its low impact on patient care and therapeutic decisions

■ Patients want imaging

■ Increases prestige of the condition

■ Refusal of imaging could be perceived as cost-saving measure

■ Postponing imaging requires more counselling time

Cooperation with orthopaedic surgeons

■ Orthopaedic surgeons are (ab)used to get rid of difficult patients.

■ Fear of being blamed of missing something albeit not important

■ Troubles with access for patients with suspicion of serious complication or severe pain

■ Routine imaging and routine prescription of physiotherapy by orthopaedic surgeons make GPs appear as "poor man's choice"

Injections

■ Injections are popular particular among elder patients

■ Replacement of injections with non-steroidals by injections of local anaesthetics

Patient education

■ There should be public education on the radio and on tv about the ineffectiveness of bed rest, imaging etc.