The New Back Pain Choices Tool

The problem

Back pain is something most of us will suffer at some point in our life. The good news is that we now understand a lot about how to effectively manage back pain. Unfortunately it is taking a while for that evidence to reach practice.

Most Australians who self-manage their back pain or seek care from a GP do not receive effective care. Surveys of consumers have shown problems such as use of ineffective treatments and taking sub-optimal doses and types of medicines. For example of the most popular treatments used by respondents to a large Australian population-based survey, half were ineffective or harmful. A large survey of Australian GP care for acute back pain revealed that less than 20% of patients received the care recommended by the NHMRC. This scenario is overwhelmingly similar in many countries around the world despite the striking consensus of back pain guidelines worldwide.

Two likely reasons for this evidence-practice gap are lack of medical training and patient’s expectations/preferences for various tests and treatments. While back pain is the 6th most common condition managed by GPs, back pain and related musculoskeletal conditions receive little attention in medical training and so it is unsurprising that GP’s knowledge on how to manage back pain often conflicts with best available evidence. While the NHMRC recommends a simple approach to managing acute low back pain this often does not align with patients’ expectations. A good example is imaging. Many patients believe that imaging will provide an explanation for their pain and GPs report that they feel pressured to provide such testing even though it has been shown that a strategy of routine imaging does not improve outcomes. However simply ignoring the patient’s expectation for imaging is unwise because patients with a strong preference for imaging often return to the same doctor or seek out a new doctor in order to get imaging.

The solution?

Researchers have studied the problem to death so it was time to do something to fix the problem. The National Prescribing Service (NPS) and the George Institute for Global Health have jointly launched a new decision support tool, Back Pain Choices, to assist primary care clinicians diagnose and manage back pain in line with best practice guidelines.

grey The New Back Pain Choices Tool

Back Pain Choices — synthesises recommendations from evidence-based practice guidelines in Australia, the UK and USA into a unified set of recommendations. It also incorporates individual patient preferences for assessments and treatments so by the end of the consultation the patient has an individually tailored management plan and/or information sheet.

Back Pain Choices steps health professionals through the process of examining, diagnosing and treating low back pain. The tool works as a communication mechanism that can be used to engage patients in discussion of low back pain treatment options. By taking this approach, both GPs and patients are made aware of the treatment options available and together they can decide on the most suitable treatment option.

The Back Pain Choices tool is now available free on the NPS website at www.nps.org.au/back-pain-choices.

About Chris Maher

grey The New Back Pain Choices Tool

Chris is Professor of Physiotherapy in Sydney Medical School, The University of Sydney and Director of the Musculoskeletal Division at The George Institute for Global Health. He leads a research division focusing on the management of musculoskeletal conditions in primary care and community settings. Prof Maher’s research evaluates the primary care management of back pain and he holds an honorary NHMRC Senior Research Fellowship and an ARC Future Fellowship.
Link to Chris’ published research here

Comments

  1. Chris – Though I like the idea of what has been done here, overall it appears that the group started with evidence and then filled in a whole bunch of gaps with opinion. It also appears that because this is supposed to be evidence-based, that there is no introduction that suggests that the evidence is guiding us to start here. Since pain and human experience are so complex and diverse, and since research is based on what works best for the average individual, we need to use our best clinical reasoning when these paths are not providing good resolution of pain and restoration of function.

    Stating that PT is expensive is not evidence-based. It is an opinion! It perpetuates a perspective that health care should be free, and is a disservice to an important aspect of health care.
    If the research shows PT is not more effective than advice and meds, during some periods of recovery, state that. Stop there!

    A second point is that this type of algorithm has the potential to create arrogance in the practitioner – as if this is all that one needs to know to help people with lbp. Blindly following it will also have the power to do wonders to foster the nocebo effect in those who somehow do not respond as one would expect to advice that there is no specific damage and they just need to start moving again.
    What does the practitioner do with the person who is 2-3 weeks out from the onset of lbp, who presents with a complex biopsychosocial picture, or who has signs of unusual pressure-pain or cold-pain allodynia? Why let the nervous systems continue freaking out just because this classification systen state it is acute pain?

    What about the inconsistent message here…
    “Rather than using pain to guide you, gradually progress your normal activity each day.”, and, “The idea is to strike a balance between being as active as you can and not irritating your back pain too much at first.” Do people understand this? if I am to not irritate my back too much, isn’t that using pain as my guide?

    How much evidence is there that says ‘the faster you get back to work the better”? That sounds like conjecture rather than a statement based on direct evidence.

    In case no one noticed, the plan is that after 4 weeks of no signficant improvement, both the patient and the MD should continue with the same treatment. is that based on evidence?

    And last – lovely that you have found the yoga research – what about the pain neurophysiology education research?

    Pathways are good guides. Clarifying what is dogma (lots of the evidence papers listed here are of others ideas of best practice rather than research of best practice guidleines), and what is evidence-based allows the reader to differentiate these, and thus question the guidelines, and patient progress, in a more circumspect manner.

  2. Chris Maher says:

    Neil-
    Back Pain Choices distils the evidence from the US, UK and Australian clinical practice guidelines. We made a very conscious decision to base the tool on high quality authoritative evidence on how to manage back pain.

    We are all human and when we read something we can take away a range of messages that may not be entirely what the authors meant. To avoid presenting an inaccurate summary of those guidelines in Back Pain Choices we asked authors from each of those guidelines to check the beta version. We also asked a GP clinician/researcher with an interest in back pain to do the same. Having followed this process we are pretty confident that Back Pain Choices accurately reflects those guidelines and is not simply opinion-based.

  3. Neil Pearson says:

    Chris – it appears you did not get past the first paragraph? No doubt that the guidelines are not only opinion-based. It is the imbedded opinions not recognised as such to which my comments point.

  4. Neil O'Connell says:

    Thanks Chris,

    I think this is nifty and for GPs particularly could be a big help. We seem to know so much more about what not to do (bedrest, imaging etc) than what to do. The treatment bit is the interesting part. I feel most guidlines seem to reflect a scratching around for convincing data rather than presenting any genuinely effective interventions. With many guidelines the “stakeholders” (hate that term) have had as much influence as the evidence. Take acupuncture – no better than sham and the effect versus convetional therapy is most likely the effect of resentful demoralisation in the usual care gtroups. But NICE went with it anyway. The funny thing is after all the nasty kerfuffle caused by the interventionists after injections did not get the nod in those guidlines, we would have to assume that had they had the sneaky nous to include a usual care group into their trials we would now be recommending injections, despite them being no better than placebo!

    But that isn’t the fault of this tool and I reckon the tool is great. Thanks loads.

  5. Mike Caruso says:

    Chris, I also appreciate what has been done here in that is takes the emphasis away from the idea that “the answer is in the image”.
    Neil makes some points. I do see potential for “create arrogance in the practitioner”.
    What happens typically here in Maryland USA is that the person with non-specific LBP gets referred for aquatics therapy for 2 months. When that does not work their benefits are cut off. They may spend the next year depressed on the couch borrowing money from friends and family to keep from being put out on the street.
    We created a big problem sailing long the course of the traditional medical model (with pain-based treatment approaches by PT) for a long time. That mindset is established in our culture. I think we need to dig in and do more.
    Guidelines should state clearly that the answer for many people is in keeping moving BUT often any movement is not enough. Performing that same faulty movement pattern embeds that in the CNS. The answer is often in improving the QUALITY of movement.
    What physicians commonly lack is an understanding of how little they know about movement science. Commonly physicians refer to PT and have no way to assess if PT did a good job or not other than asking the patient. If we are going to make real progress physicians need better tools.
    One place we can look for a system of movement assessment that has been field tested was developed for professional athletes- the Functional Movement System (Gray Cook Team). The SFMA component or some version of it, may be a good tool for all involved- most importantly the patient. Patients can do very little about that disc herniation but they can learn to think and work on their movement quality when you show it to them.
    Recently, I showed a firefighter with 10 years of low back pain and intermittent right leg pain when standing, that his right hip lacked extension and that he was very unstable in the in-line lunge on the right knee. He got that on the first visit. He was thinking a lumbar fusion was the answer but was hesitant because he knew the likelihood of returning to his job after a fusion was poor.
    He is back to work full duty with no pain AND next time he has pain with movement he may be thinking about the quality of the movement not what the image will show.

  6. Chris Maher says:

    Neil – if you feel that the parent guidelines are not evidence-based then make your case and send it off to each agency that produced these guidelines. It may well be that you know more about science than those agencies. Or it may be that you are mistaken.

  7. Chris, I would rather not deflect this issue elsewhere. From my potentially mistaken view, these new guidelines start with an evidence-based look at categories of lbp troubles, and a simple algortihm for MDs. Then once we look at the treatment suggestions, the guidelines go beyond the evidence without clearly differentiating what is directed by evidence, and what is best-opinion. The two strongest examples I remember from my read are the opinion about the expensiveness of PT, and the comment that the faster one returns to work, the better.
    Sure it would be great if all health care was paid for by the government, but it is not. The inference in the guidelines points at Physical Therapists as being expensive, whether that was the intention. Do you really want patients who would benefit from PT believing that it is expensive? And certainly getting back to as normal life as possible as soon as is safe is a good idea. Yet the research does not say that faster is better. It infers that waiting until all the pain and dysfunction is resolved is a very poor choice. We do not know the optimal speed for RTW.
    It is my hope that MANY PTs will respond to the NPS website requesting both greater clarity, and removal of the not-evidence-based comment that PTs are expensive.

  8. Great post Chris – thanks for taking the time to write this up for BiM. It has clearly generated some interest. For my two Australian Peso’s worth, I think Neil P raises some very interesting and important points, primarily identifying the limitations of any synthesis of the literature and the guidelines which are, as Neil OC observes, a reflection of stake-holder interests as well as top level AVAILABLE evidence. I would expect that the statement in the BPC programme about physiotherapy being ‘expensive’ would be more precisely written as ‘poorer cost to clinical benefit ratio than some other options’. Would this expectation be accurate Chris? Is there talk in your ‘pointy end of the public health implications of back pain’ world of a term that works like NNT, but is actually FNT – funds needed to treat? (I originally had that as ‘cash needed to treat’, but that is a problematic acronym indeed).
    I am sympathetic to the problems that Neil P identifies with the algorithm approach, although I know that there are very large and influential movements out there who are really promoting such algorithms. While they might de-emphasise the complexity of pain, as Neil P suggests, when they reflect the final consequence of collective clinical reasoning, they can be terrifically powerful and the backbone of differential diagnoses. If we could establish an algorithm that included the entirety of potential contributions to pain, it would be a Nobel Prize winner. Perhaps one day we will – I know people far more clever than I who are actually engaging with that in a tangible way. One of my mates does work on algorithms that predict locust swarm behaviour – that’s got to be pretty complex. Regardless, I can personally vouch for both of the main protagonists here that the other protagonist has their heart entirely in the right spot. It is places like BiM where we might promote the revolution by bringing both perspectives to the table. So, I am very grateful for your contributions. As they say in the current home of the Olympic festival ‘Carry on and drink some tea’.

  9. Chris Maher says:

    Neil
    I am not sure where the tool says Physical Therapists are expensive. We consciously tried to keep the names of professions out of the tool and acknowledged that there are a range of professions providing exercise, manual therapies and physical therapies.

    We have a couple of sentences on costs of these treatments eg this one

    “Out of pocket costs to patients for a course of these physical therapies can be expensive – inform the patient on out of pocket expenses that would be incurred so they can make an informed choice. ”

    and this one

    “Inform the patient on out of pocket expenses that would be incurred so they can make an informed choice.”

    In both sentences the emphasis is on giving the patient appropriate information about cost so they can make an informed choice.

  10. Michael Ward says:

    Hi Chris (and others), in presenting this NPS content re acute LBP to GPs, I have been asked “when should I refer patients on”, amongst a range of other questions. This isnt as straight forward as might first appear. Cost is relevant and varies across public health funding. In Aus, appropriately provided advice from the GP is often free to the patient (a cost to the gov thru medicare) but AH is a cost to the patient. Not every patient (and a good proportion in my region) is able to afford private Allied Health input. So from a public health initiative, it is important that GPs can provide evidence guided care – Triage of red flags vs simple mechanical LBP; appropriate imaging and able to address patient concerns; appropriate medication and simple pain management strategies. Secondly, I have seen (unfortunately too frequently) allied health providers that have a business model that makes casinos and tobacco companies look ethical, stripping money from the pt or their health fund (if they have one), while providing contra-evidenced care and engendering dependence. So GPs need to be able to recognise and differentiate between good and bad care. Thirdly, the initiative is directed at the acute back pain patient with low complexity. Keep in mind the incidence of LBP (?85%) versus the development of complex chronic LBP (??5-10%), which require the greatest proportion of funds for management. We should not over medicalise a condition which for the greater proportion do not require much input – dont apply a chronic pain model to a simple problem. Only sports medicine has succeeded in justifying a more expensive model of health care for so few.
    AH are considered part of the NPS initiative but as part of an overall algorithm with avenues for GPs to consider their value in both mechanical LBP and LBP where yellow flags are emergent. Overall, I think that the NPS program is a positive public health initiative.

    My major concern with LBP or WAD guidelines which recommend usual activity and keep active are that this is fraught with danger – either perceived as patronising or poorly communicated such that it is nonsensical when a patient is experiencing such a severe episode that it is unworkable immediately and so the essence of the message is lost.
    Cheers

  11. This is a great discussion so far. As I’m currently involved in a project working on actionable messages for neck pain, I can sympathize with the different perspectives offered here so far. A couple of things come to mind which I’ll share, perhaps they will lead somewhere, perhaps they won’t. I echo Lorimer’s statement that clearly all opinionists have their hearts in the right place, and I have nothing but respect for both Neils and Chris. Neil P is a very clever fellow, and I can’t help but think that if he has misinterpreted a statement made in the guideline, or at least sees where it could be misinterpreted, that other people either less clever or in more of a hurry could also misinterpret it. This might be a good reason to at least consider revising the statement somehow. Consider it a KT exercise perhaps – cognitive debriefing or something of that sort. I would indeed be bothered if people were not sent to physio or other rehab due simply to a primary provider misinterpreting a statement about the expense of such.

    My other point is around this idea of ‘earlier back to work the better’. I can’t speak authoritatively about the evidence in LBP, but at least in my field (whiplash and neck pain), there’s a somewhat endemic problem with reverse causation, or rather a lack of respect thereof, in interpreting those results. I’ve got a fair amount of research here that suggests that people who return to work earlier are better off at a fixed follow-up point. Of course, that may simply mean that people who were less affected by the injury/condition are more likely to return to work earlier. I still sometimes shudder when I think of how many medical and rehab providers I know push people back to work too early based on their (mis)interpretation of these kinds of finding. I quite like Natalie Spearing and Luke Connelly’s paper describing reverse causality as it pertains to the compensation hypothesis (http://www.ncbi.nlm.nih.gov/pubmed/22020600) and think it probably holds in the ‘early return to work’ hypothesis in neck pain at least.
    Again, I’m no authority in LBP work, and perhaps the same problem doesn’t exist there. I suppose this is now more of a question than a comment for Chris if you’re so inclined – do you see this same sort of problem with reverse causation in the LBP lit? If so, have you been able to address it in the guidelines?
    All in all I quite like the tool itself and the way its presented, thanks for sharing the information Chris. As with most such things I’m sure there’s room for improvement. I’m sure NPS will consider collection and consideration of feedback such as that which Neil has offered here in future iterations.
    Cheers.

  12. Back pain can significantly affect your quality of life. Its good that they have now made this tool available! Thank you very much for sharing.