Can Primary Care Provide Effective Management of Chronic Pain?

2,256 views

Published on

This lecture was given by Professor Gary Macfarlane, Professor of Epidemiology at the University of Aberdeen, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. Professor Macfarlane is introduced by Dr Colin Rae. The lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".

www.wspg.org.uk

Published in: Health & Medicine
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,256
On SlideShare
0
From Embeds
0
Number of Embeds
71
Actions
Shares
0
Downloads
166
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide
  • Can Primary Care Provide Effective Management of Chronic Pain?

    1. 1. Can Primary Care Provide Effective Management of Chronic Pain? Gary J Macfarlane Professor of Epidemiology
    2. 2. Outline <ul><li>Background </li></ul><ul><li>Predictors of onset and outcome of low back pain presenting to general practice </li></ul><ul><li>Evidence on management from systematic reviews and recent trials </li></ul><ul><li>Future directions in management </li></ul>
    3. 3. 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
    4. 4. Consulting for LBP Consultation pattern % consulters <ul><li>Most persons consult once only </li></ul><ul><li>Consultation more than three months after initial consultation is very rare </li></ul>
    5. 5. Consulting for LBP Time since consultation % consulters <ul><li>25% consulters are symptom free one year later </li></ul><ul><li>50% have pain and disability </li></ul>Pain and Disability Symptom free
    6. 6. Low Back Pain Guidelines National guidelines on primary care management in 12 countries Differences : development groups, target populations, methods used
    7. 7. Diagnostic Triage Non-specific back pain Nerve root pain Possible serious spinal pathology (“red flag”)
    8. 8. Management of non-specific back pain Gradual and early activation Avoidance of bed rest Acknowledge role of psychosocial factors Koes et al, 2001
    9. 9. Outline <ul><li>Background </li></ul><ul><li>Predictors of onset and outcome of low back pain presenting to general practice </li></ul><ul><li>Evidence on management from systematic reviews and recent trials </li></ul><ul><li>Future directions in management </li></ul>
    10. 10. 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
    11. 11. Environment Obesity Lack of exercise Cigarette smoking Lifestyle
    12. 12. Environment Workplace: Mechanical factors
    13. 13. Mechanical (injury)
    14. 14. Environment Workplace: Psychosocial factors
    15. 15. Psychosocial factors in the workplace <ul><li>Demands </li></ul><ul><ul><li>high (stress) </li></ul></ul><ul><ul><li>low (monotony) </li></ul></ul><ul><li>Control </li></ul><ul><li>Support </li></ul><ul><ul><li>colleagues </li></ul></ul><ul><ul><li>superiors </li></ul></ul><ul><li>Satisfaction </li></ul>
    16. 16. Thomas et al, 1999 Predicting persistence of back pain South Manchester LBP Study (UK) <ul><li>Demography: Female Gender </li></ul><ul><li>Clinical: Recurrent Episode </li></ul><ul><ul><ul><ul><li>Leg Pain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Spinal Restriction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Widespread body pain </li></ul></ul></ul></ul><ul><li>Psychosocial: Workplace dissatisfaction </li></ul>
    17. 17. 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 <ul><li>Female Gender </li></ul><ul><li>Recurrent Episode </li></ul><ul><li>Leg Pain </li></ul><ul><li>Widespread pain </li></ul><ul><li>Spinal restriction </li></ul><ul><li>Workplace </li></ul><ul><li>Dissatisfaction </li></ul>Number of risk factors South Manchester LBP Study (UK)
    18. 18. Psychological predictors of persistence: Systematic Review Strong evidence Psychological distress Depressive mood Coping strategy Somatisation Pincus et al, 2002 Evidence Weak evidence
    19. 19. Onset and outcome of LBP <ul><li>We have identified </li></ul><ul><li>factors putting people </li></ul><ul><li>at higher risk of LBP </li></ul><ul><li>We can identify those </li></ul><ul><li>at consultation whose </li></ul><ul><li>symptoms are likely to </li></ul><ul><li>persist </li></ul><ul><li>What can we do about it in terms of primary and secondary prevention? </li></ul><ul><li>What factors can we CHANGE? </li></ul>
    20. 20. Environmental factors <ul><li>Lifestyle </li></ul><ul><ul><li>Physical activity, obesity, cigarette smoking </li></ul></ul><ul><li>Workplace </li></ul><ul><ul><li>Mechanical load, posture, forceful movements, psychosocial factors (job demands, support and control) </li></ul></ul>
    21. 21. Episode-specific factors <ul><li>Demography </li></ul><ul><li>Clinical </li></ul><ul><li>Psychological and Psychosocial </li></ul><ul><ul><li>mood disorders </li></ul></ul><ul><ul><li>coping strategies </li></ul></ul>
    22. 22. Outline <ul><li>Background </li></ul><ul><li>Predictors of onset and outcome of low back pain presenting to general practice </li></ul><ul><li>Evidence on management from systematic reviews and recent trials </li></ul><ul><li>Future directions in management </li></ul>
    23. 23. Pharmacological therapies <ul><li>NSAIDs and muscle relaxants effective for the </li></ul><ul><li>short-term relief of acute LBP </li></ul>Non- Pharmacological therapies <ul><li>Advice to remain active improves short- and </li></ul><ul><li>long- term outcome </li></ul>
    24. 24. Other therapies <ul><li>Physical therapies </li></ul><ul><li>Exercise </li></ul><ul><li>Behavioural therapies </li></ul><ul><li>Pain Management Programmes </li></ul><ul><li>Psychosocial Interventions </li></ul>
    25. 25. BMJ 2005; 330: 674 Best “Usual care” +/- Exercise +/- Manipulation
    26. 26. LBP Functional Outcome
    27. 27. BMJ 2004; 329: 708
    28. 28. Baseline 2 6 12 months Change: Roland and Morris Disability Qu . Advice Physiotherapy
    29. 29. Lancet 2005; 365:2024
    30. 30. Pain management (n = 201) Manual Physiotherapy (n = 201) Completely/ much better (%) 68 Satisfaction with treatment (0-100 mm) 93 69 93 LBP Functional Outcome
    31. 31. BMJ 2005; 331:84
    32. 32. 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
    33. 34. 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
    34. 35. 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
    35. 36. LBP Management <ul><li>Disappointing results from recent trials of management in primary care </li></ul><ul><ul><li>No improvement v. usual (conservative) care </li></ul></ul><ul><ul><li>No difference between alternative management </li></ul></ul>
    36. 37. Outline <ul><li>Background </li></ul><ul><li>Predictors of onset and outcome of low back pain presenting to general practice </li></ul><ul><li>Evidence on management from systematic reviews and recent trials </li></ul><ul><li>Future directions in management </li></ul>
    37. 38. 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
    38. 39. 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 ?
    39. 40. <ul><li>2 states in Australia </li></ul><ul><li>Public Media Campaign in Victoria </li></ul><ul><ul><li>Staying active and exercising </li></ul></ul><ul><ul><li>Not resting for prolonged periods </li></ul></ul><ul><ul><li>Staying at work </li></ul></ul>BMJ 2001; 322: 1516-20 <ul><li>Back Book made widely available </li></ul><ul><li>Doctors received evidence-based guidelines </li></ul>
    40. 42. Back Beliefs: Population-level
    41. 43. Other outcomes <ul><li>Significant improvement in knowledge and attitudes of GPs </li></ul><ul><li>Workers’ compensation claim for back pain decreased </li></ul><ul><li>Medical payments for back pain reduced </li></ul>
    42. 44. Knowledge and Attitudes of LBP: GPs <ul><li>Significant improvement in knowledge and attitudes of GPs maintained at 4.5 years </li></ul><ul><li>GPs from Victoria were: </li></ul><ul><li>x 2.0 “back pain patients need not wait until </li></ul><ul><li>pain-free before return to work” </li></ul><ul><li>x 1.8 “not to order tests for acute back pain” </li></ul><ul><li>x 0.5 “to prescribe bed-rest” </li></ul>
    43. 45. 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
    44. 46. 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 ?
    45. 47. 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
    46. 48. Different approaches to identifying subgroups <ul><li>Classify patients on the basis of presenting clinical factors (classification tools) </li></ul><ul><li>Classify patients on the basis of factors that predict future outcome (prognostic tools) </li></ul><ul><li>Identify subgroups on the basis of likely response to treatment (clinical prediction rules) </li></ul><ul><li>Combinations of the above [STarT Back] </li></ul>
    47. 49. The STarT Back Approach <ul><li>“ Identify subgroups by screening for prognostic indicators that can be targeted with available treatment options” </li></ul><ul><li>Primary Care Context: </li></ul><ul><li>Problems Solutions </li></ul>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
    48. 50. Available treatment options <ul><li>Low risk subgroup – pts with a good prognosis, suitable for primary care management according to best practice guidelines </li></ul>
    49. 51. Available treatment options <ul><li>Low risk subgroup – pts with a good prognosis, suitable for primary care management according to best practice guidelines </li></ul><ul><li>Medium risk subgroup – pts with a poor prognosis, with modifiable prognostic indicators that need early targeting (e.g. physical therapy) </li></ul>
    50. 52. Available treatment options <ul><li>Low risk subgroup – pts with a good prognosis, suitable for primary care management according to best practice guidelines </li></ul><ul><li>Medium risk subgroup – pts with a poor prognosis, with modifiable prognostic indicators that need early targeting (e.g. physical therapy) </li></ul><ul><li>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. </li></ul>
    51. 53. 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
    52. 54. Overall aim of the Clinical Trial <ul><li>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? </li></ul><ul><li>A pilot study completed </li></ul><ul><li>Now beginning a full randomised clinical trial (n=800) </li></ul>
    53. 55. 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 ?
    54. 56. Patient Beliefs <ul><li>Patients with lower limb OA were at increased risk of disability if they believed that it </li></ul><ul><ul><li>had a large impact on functioning </li></ul></ul><ul><ul><li>was likely to be of long duration </li></ul></ul><ul><ul><li>Botha-Scheepers et al, 2006 </li></ul></ul>
    55. 57. Johnson et al, 2007 Spine (in press)
    56. 58. -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
    57. 59. 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 ?
    58. 60. <ul><li>We understand a great deal about the aetiology of onset and outcome of LBP </li></ul><ul><li>We have been less successful at translating this evidence into improved patient outcomes </li></ul><ul><li>Interventions both at the population and individual level (primary care) likely to be most successful </li></ul>

    ×