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

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, 1995 Population: 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+ Prevalence (%) Lifetime prevalence 1-year prevalence 1-year consultation

Consulting for LBP Consultation pattern % consulters Most persons consult once only Consultation more than three months after initial consultation is very rare

Most persons consult once only

Consultation more than three months after initial consultation is very rare

Consulting for LBP Time since consultation % consulters 25% consulters are symptom free one year later 50% have pain and disability Pain and Disability Symptom free

25% consulters are symptom free one year later

50% have pain and disability

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

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/II Professional III Non-Manual III Manual IV/V Non-Skilled Prevalence (%) Palmer et al, 2000 Social class

Environment Obesity Lack of exercise Cigarette smoking Lifestyle

Environment Workplace: Mechanical factors

Mechanical (injury)

Environment Workplace: Psychosocial factors

Psychosocial factors in the workplace Demands high (stress) low (monotony) Control Support colleagues superiors Satisfaction

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

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 % with back pain at 3 months 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)

Female Gender

Recurrent Episode

Leg Pain

Widespread pain

Spinal restriction

Workplace

Dissatisfaction

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?

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)

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

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

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

NSAIDs and muscle relaxants effective for the

short-term relief of acute LBP

Advice to remain active improves short- and

long- term outcome

Other therapies Physical therapies Exercise Behavioural therapies Pain Management Programmes Psychosocial Interventions

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

Baseline 2 6 12 months Change: Roland and Morris Disability Qu . Advice Physiotherapy

Lancet 2005; 365:2024

Pain management (n = 201) Manual Physiotherapy (n = 201) Completely/ much better (%) 68 Satisfaction with treatment (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 care Roland and Morris Disability Psychosocial interventions

Roland and Morris Disability Score Change 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 Pain (Vas) Change Score 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

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

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

2 states in Australia

Public Media Campaign in Victoria

Staying active and exercising

Not resting for prolonged periods

Staying at work

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

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”

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 Back Pain Beliefs Questionnaire Intervention 26.1 26.3 26.2 26.3 NSW 28.8 29.7 28.4 26.5 Victoria 3 years later After During Before

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 S ub-grouping for Tar geted T reatment in 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]

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 A systematic approach to treatment Treatment provision is inconsistent Early targeted intervention before problems become entrenched Treatment modifiable prognostic indicators are identified too late Prognostic assessment is possible Diagnosis is difficult

“ Identify subgroups by screening for prognostic indicators that can be targeted with available treatment options”

Primary Care Context:

Problems Solutions

Available treatment options Low risk subgroup – pts with a good prognosis, suitable for primary care management according to best practice guidelines

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)

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.

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)

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

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 better Pain (Vas) Change Score 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

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