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Aberdeen Pain Research Collaboration
Epidemiology Group, Department of Public Health
Can Primary Care Provide Effective Management of Chronic Pain?
Gary J Macfarlane
Professor of Epidemiology
Outline
• Background
• Predictors of onset and outcome of low back pain presenting to general practice
• Evidence on management from systematic reviews and recent trials
• Future directions in management
Lifetime prevalence of back pain
Papageorgiou et al, 1995Population: Manchester, UK (N=7669)
South Manchester LBP study 1991-3
0
10
20
30
40
50
60
70
80
18-29 30-44 45-59 60+
Pre
vale
nce
(%
) Lifetime prevalence
1-year prevalence
1-year consultation
Consulting for LBP
Consultation pattern
% c
onsu
lters
• Most persons consult once only
• Consultation more than three months after initial consultation is very rare
Consulting for LBP
Time since consultation
% c
onsu
lters
• 25% consulters are symptom free one year later
• 50% have pain and disability
Pain and Disability
Symptom free
Low Back Pain Guidelines
National guidelines on primary care management in 12 countries
Differences : development groups, target populations, methods used
Diagnostic Triage
Non-specific back pain
Nerve root pain
Possible serious spinal pathology(“red flag”)
Management of non-specific back pain
Gradual and early activation
Avoidance of bed rest
Acknowledge role of psychosocial factors
Koes et al, 2001
Outline
• Background
• Predictors of onset and outcome of low back pain presenting to general practice
• Evidence on management from systematic reviews and recent trials
• Future directions in management
Environment
0
10
20
30
40
50
60
70
80
I/IIProfessional
IIINon-Manual
IIIManual
IV/VNon-Skilled
Pre
vale
nce
(%)
Palmer et al, 2000
Social class
Environment
Obesity
Lack of exercise
Cigarette smoking
Lifestyle
EnvironmentWorkplace:
Mechanical factors
Mechanical (injury)
EnvironmentWorkplace:
Psychosocial factors
Psychosocial factors in the workplace
• Demands– high (stress)
– low (monotony)
• Control
• Support– colleagues
– superiors
• Satisfaction
Thomas et al, 1999
Predicting persistence of back pain
South Manchester LBP Study (UK)
• Demography: Female Gender
• Clinical: Recurrent Episode
Leg Pain
Spinal Restriction
Widespread body pain
Psychosocial: Workplace dissatisfaction
0
10
20
30
40
50
60
70
80
0 - 2 3 4 5 - 6
% w
ith
bac
k p
ain
at
3 m
on
ths
Predicting persistence of back pain
• Female Gender
• Recurrent Episode• Leg Pain• Widespread pain• Spinal restriction
• Workplace Dissatisfaction
Number of risk factors
South Manchester LBP Study (UK)
Psychological predictors of persistence: Systematic Review
Strong evidence
Psychological distress
Depressive mood
Coping strategy
Somatisation
Pincus et al, 2002
Evidence
Weak evidence
Onset and outcome of LBP
• We have identified
factors putting people
at higher risk of LBP
• We can identify those
at consultation whose
symptoms are likely to
persist
• What can we do about it in terms of primary and secondary prevention?
• What factors can we CHANGE?
Environmental factors
• Lifestyle
– Physical activity, obesity, cigarette smoking
• Workplace
– Mechanical load, posture, forceful movements, psychosocial factors (job demands, support and control)
Episode-specific factors
• Demography
• Clinical
• Psychological and Psychosocial
• mood disorders
• coping strategies
Outline
• Background
• Predictors of onset and outcome of low back pain presenting to general practice
• Evidence on management from systematic reviews and recent trials
• Future directions in management
Pharmacological therapies
• NSAIDs and muscle relaxants effective for the
short-term relief of acute LBP
Non- Pharmacological therapies
• Advice to remain active improves short- and
long- term outcome
Other therapies
• Physical therapies
• Exercise
• Behavioural therapies
• Pain Management Programmes
• Psychosocial Interventions
BMJ 2005; 330: 674
Best “Usual care”
+/- Exercise +/- Manipulation
LBP Functional Outcome
BMJ 2004; 329: 708
-5
-4
-3
-2
-1
0
1
2
3
4
5
Baseline 2 6 12 months
Ch
ang
e: R
ola
nd
an
d M
orr
is D
isab
ilit
y Q
u.
Advice
Physiotherapy
Lancet 2005; 365:2024
Pain management(n = 201)
Manual Physiotherapy(n = 201)
Completely/much better (%)
68
Satisfaction withtreatment (0-100 mm)
93
69
93
LBP Functional Outcome
BMJ 2005; 331:84
Psychosocial Interventions v. Usual Care
0
3
6
9
12
15
18
21
24
0 3 6 9 12
Months
Usual carePsychosocial interventions
Rol
and
and
Mor
ris
Dis
abil
ity
Ro
lan
d a
nd
Mor
ris
Dis
abi
lity
Sco
re C
ha
nge
3 6 9 12 15
Months
Group Sessions better
Usual Care better
LBP Functional Outcome
12
9
6
3
0
-3
-6
3 6 9 12 15
Group Sessions better
Usual Care better
30
20
10
0
-10
-20
-30
Pai
n (V
as)
Cha
nge
Sco
re
LBP Pain Outcome
LBP Management
• Disappointing results from recent trials of management in primary care
– No improvement v. usual (conservative) care– No difference between alternative management
Outline
• Background
• Predictors of onset and outcome of low back pain presenting to general practice
• Evidence on management from systematic reviews and recent trials
• Future directions in management
Informing management:
Re-think expectations ?
Interventions- individual/populations- target risk factors- patient beliefs
Re-examine aetiology of onset and outcome ?
Improved measurement of known risk factors ?
Future Directions in Management
Informing management:
Re-think expectations ?
Interventions- individual/populations- target risk factors- patient beliefs
Re-examine aetiology of onset and outcome ?
Improved measurement of known risk factors ?
• 2 states in Australia• Public Media Campaign in Victoria
– Staying active and exercising
– Not resting for prolonged periods
– Staying at work
BMJ 2001; 322: 1516-20
• Back Book made widely available
• Doctors received evidence-based guidelines
Back Beliefs: Population-level
Other outcomes
• Significant improvement in knowledge and attitudes of GPs
• Workers’ compensation claim for back pain decreased
• Medical payments for back pain reduced
Knowledge and Attitudes of LBP:GPs
• Significant improvement in knowledge and attitudes of GPs maintained at 4.5 years
• GPs from Victoria were:
x 2.0 “back pain patients need not wait until
pain-free before return to work”
x 1.8 “not to order tests for acute back pain”
x 0.5 “to prescribe bed-rest”
Back Beliefs: Population-level
Before During After 3 years later
Victoria 26.5 28.4 29.7 28.8
NSW 26.3 26.2 26.3 26.1
Back Pain Beliefs Questionnaire
Intervention
Informing management:
Re-think expectations ?
Interventions- individual/populations- target risk factors- patient beliefs
Re-examine aetiology of onset and outcome ?
Improved measurement of known risk factors ?
The STarT Back Screening Study
Sub-grouping for Targeted Treatmentin Low Back Pain
The STarT Back Team:
EM Hay, S Somerville, JC Hill, E Mason, C Vohora, T Whitehurst,
G Sowden, K Konstantinou, CJ Main, K Dunn, J Bailey, C Calverley
University of Keele
Different approaches to identifying subgroups
• Classify patients on the basis of presenting clinical factors
(classification tools)
• Classify patients on the basis of factors that predict future outcome
(prognostic tools)
• Identify subgroups on the basis of likely response to treatment
(clinical prediction rules)
• Combinations of the above [STarT Back]
The STarT Back Approach
“Identify subgroups by screening for prognostic indicators that can be
targeted with available treatment options”
Primary Care Context:
Problems Solutions
Diagnosis is difficult Prognostic assessment is possible
Treatment modifiable prognostic indicators are identified too late
Early targeted intervention before problems become entrenched
Treatment provision is inconsistent A systematic approach to treatment
Available treatment options
Low risk subgroup – pts with a good prognosis, suitable for primary care
management according to best practice guidelines
Available treatment options
Low risk subgroup – pts with a good prognosis, suitable for primary care
management according to best practice guidelines
Medium risk subgroup – pts with a poor prognosis, with modifiable
prognostic indicators that need early targeting (e.g. physical therapy)
Available treatment options
Low risk subgroup – pts with a good prognosis, suitable for primary care
management according to best practice guidelines
Medium risk subgroup – pts with a poor prognosis, with modifiable
prognostic indicators that need early targeting (e.g. physical therapy)
High risk subgroup – patients with a very poor prognosis, with high levels of
psychosocial (+/- physical) prognostic indicators, suitable for referral to
practitioners trained in cognitive behavioural approaches.
STarT Back Screening Tool
Patient with
prognostic indicators
of persistent LBP
A mix of different
prognostic indicators
Patient without
prognostic indicators
of persistent LBP
Low risk 26%
High risk 26% Medium risk 48%
High psychosocial prognostic indicators
Overall aim of the Clinical Trial
Does “sub-grouping for targeted treatment” based on a
prognostic screening approach improve long-term outcomes
for primary care patients with back pain compared to usual
care?
A pilot study completed
Now beginning a full randomised clinical trial (n=800)
Informing management:
Re-think expectations ?
Interventions- individual/populations- target risk factors- patient beliefs
Re-examine aetiology of onset and outcome ?
Improved measurement of known risk factors ?
Patient Beliefs
• Patients with lower limb OA were at increased risk of disability if they believed that it
– had a large impact on functioning
– was likely to be of long duration
Botha-Scheepers et al, 2006
Johnson et al, 2007 Spine (in press)
-30
-20
-10
0
10
20
30
3 6 9 12 15
Group Sessions better
Usual Care betterPai
n (V
as)
Cha
nge
Sco
re
LBP Pain Outcome: Patient Preference
Informing management:
Re-think expectations ?
Interventions- individual/populations- target risk factors- patient preference
Re-examine aetiology of onset and outcome ?
Improved measurement of known risk factors ?
• We understand a great deal about the aetiology of onset and outcome of LBP
• We have been less successful at translating this evidence into improved patient outcomes
• Interventions both at the population and individual level (primary care) likely to be most successful