Why do we need a clinical care standard for low back pain?

In Australia, low back pain is the leading cause of disability burden, lost work productivity and early retirement.

It is important that we get treatment right but unfortunately that is not always the case.

We now know pretty clearly how low back pain should be managed and Australian physiotherapists have played a key role in generating that evidence base. 

A recent example is the game-changing RESTORE, RESOLVE and OPAL trials led by Australian physiotherapists.

They tell us what not to provide—oxycodone for acute spinal pain (OPAL)—and what we should provide— cognitive functional therapy (RESTORE) or graded sensorimotor training (RESOLVE) for chronic low back pain.

The challenge is now one of changing practice.

How does clinicians’ behaviour need to change to align with the standard?

All patients should receive an initial clinical assessment that includes a psychosocial assessment to guide the management plan. 

In most patients seen in primary care, there will be no alerting features and the patient should be encouraged to stay active and continue or return to usual activity, including work, as soon as possible. 

Self-management strategies can also be discussed with the patient. 

For these patients, physiotherapy management may simply entail the initial assessment and a review at one to two weeks to confirm recovery. 

This will be a different way of practising for some physiotherapists.

In other patients, the initial assessment will identify barriers to recovery and the management plan will need to include physical and/or psychological interventions targeted at these barriers. 

While in the past it was believed that physiotherapists should confine their practice to the provision of physical therapies such as exercise and manual therapy, it is now well accepted that cognitive and behavioural approaches should be a seamless part of physiotherapy practice when managing low back pain. 

There are good resources (eg, restorebackpain.com here and painhealth.csse.uwa.edu.au here) that can help physiotherapists incorporate these new approaches into their care.

How do healthcare services need to change to align with the standard? 

The funders and providers of healthcare services need to ensure that they enable and reward care that is in alignment with the standard. 

That will require significant change because most systems have been established to support a very old-fashioned model of care for low back pain. 

Vested interests have further complicated the situation because many of the low value procedures are quite lucrative for their industry and providers.

Chris Maher.

Where the physiotherapy profession can help is to raise awareness of the importance of basing provision and funding of health services on evidence of (cost) effectiveness and safety. 

In this endeavour we have many natural partners. 

Governments, health departments, insurers and trade unions share an interest in ensuring that the quality care outlined in the standard is available to all Australians.

Are there resources available to support adoption of the standard? 

The Commission’s website here contains useful information supporting adoption of the standard and allowing clinicians and healthcare services to monitor how well they are implementing the care advocated in the standard.

Resources include:

•    quick guides for clinicians with evidence summaries and suggestions for effective communication
•    fact sheets for patients outlining key information about back pain and self-management strategies
•    a webcast launch event attracting a high number of views and keen media interest
•    a joint editorial providing multidisciplinary support for the standard published concurrently in several key professional journals
•    a GP online learning module and a communications package to support Primary Health Networks
•    a consumer video highlighting the impact of current practice on patients experiencing back pain.

To assist physiotherapists to implement the standard, the APA collaborated with the Commission to develop a Quick Guide for Physiotherapists. Click here for more information.

>> Professor Chris Maher FACP is a physiotherapist and the director of the Institute for Musculoskeletal Health, the University of Sydney/ Sydney Local Health District.

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