The problem of low back pain

Low back pain is the leading cause of disability burden in Australia (GBD 2015 Disease and Injury Incidence and Prevalence Collaborators 2016), costing the Australian health system $4.8 billion annually (Arthritis and Osteoporosis Victoria 2013).

The influential 2018 Lancet low back pain series (Buchbinder et al 2018, Foster et al 2018, Hartvigsen et al 2018) proposed that low back pain’s societal burden is driven by an epidemic of ‘low value’ care.

This includes the inappropriate use of imaging, the overuse of pain medicines (such as opioids) and spinal surgery, and an over-reliance on passive treatments, with a predominant focus on symptom palliation.

What does best practice care look like?

Understanding of best practice care for patients with low back pain has evolved over the past decades (Lin et al 2020).

Pain medicines, bed rest and surgery are now recognised as having a limited role in most cases of low back pain (Lin et al 2020, Maher et al 2017, Chiarotto et al 2022).

Imaging should be reserved for patients with suspected serious pathology or fracture, as routine imaging does not improve patient outcomes (Maher et al 2017).

In cases where serious pathology is not suspected (approximately 95 per cent of presentations, depending on the care setting), identifying and addressing physical and psychosocial barriers to recovery is central to first-line care (Lin et al 2020, Traeger et al 2021).

This care should be patient-centred, where the clinician responds to the patient’s individual context, employs effective communication and uses shared decision-making processes (Lin et al 2020).

Professor Chris Maher.

This includes patient-specific reassurance and validation, education that promotes a positive mindset about their condition and advice that encourages self-management.

Building the confidence to engage with movement, physical activity, social activities and work is central to this (Lin et al 2020).

For patients who do not respond to this first-line care, or where a risk assessment suggests that they may not respond, the provision of more targeted physical and psychological therapies that address the barriers to recovery is indicated (Chiarotto et al 2022).

A program of graded exercise therapy to help patients build the confidence to engage with normal movement and activities in line with their goals may facilitate this process.

Time- limited manual therapy may provide pain relief as an adjunct to active management (Lin et al 2020).

Where psychosocial factors dominate the patient presentation, psychological referral is warranted.

If the patient’s condition has not recovered as anticipated or is deteriorating, it is important to review them to reconsider their diagnosis, assess for red flags and review ongoing physical and psychosocial barriers to recovery.

Based on this assessment, appropriate referral for further investigation and/or specialised care should be made (Lin et al 2020).

What is a clinical care standard?

In September 2022 the Australian Commission on Safety and Quality in Health Care (the Commission) released its Low Back Pain Clinical Care Standard.

Guided by a comprehensive review of international and local guidelines, the standard was drafted over a series of meetings by the Commission and a working group comprised of representatives of the professions who manage low back pain, NPS MedicineWise, consumer advocacy groups and independent experts.

The standard was sent to professional associations for feedback and the final version was endorsed by 19 professional associations (including the APA).

Clinical care standards focus on key areas of care where the need for quality improvement is greatest rather than providing an exhaustive coverage of all aspects of management as would be the case with a clinical practice guideline.

A clinical care standard contains a limited number of quality statements that specify the care patients should be provided by clinicians and health services for their health condition concordant with current best evidence.

Within care standards there are also quality indicators to allow clinicians and health services to measure how well they are implementing the care specified in the standard.

What does this mean for physiotherapy practice?

Physiotherapists are often first contact practitioners for people seeking care for low back pain.

However, many physiotherapists do not follow evidence-based guidelines when managing patients with low back pain (Zadro et al 2019).

Professor Peter O'Sullivan.

The Low Back Pain Clinical Care Standard provides physiotherapists with an opportunity to play a central role in the provision of best practice care for people with low back pain.

Quality statements within the standard describe what best practice care should entail for all clinicians, while the Quick guide for physiotherapists (see link below) provides an overview of the care described in the standard, with key actions and communication tips for physiotherapists.

To implement the standard in their practice, physiotherapists will need to reduce or stop the use of some interventions they have traditionally used and they might need to take up some new approaches that are unfamiliar to them.

This is likely to require learning new skills and styles of work to support the care model described in the standard.

The standard also provides physiotherapists with a clear framework for the timely referral of their patients to other healthcare professionals when additional or alternative care is indicated.

Are there other resources to support adoption of the Low Back Pain Clinical Care Standard?

The Commission has produced resources to support uptake of the standard and to help clinicians and healthcare services monitor how well they are delivering the care described.

They include consumer resources (a consumer guide explaining the standard, self-management information and answers to common questions about low back pain), quick guides for general practitioners and emergency departments, and fact sheets for clinicians and healthcare services.

These resources are freely available on the Commission’s website. 

Conclusion

The Low Back Pain Clinical Care Standard meets a pressing need for a clear road map for how to deliver best practice care for people with low back pain.

The standard presents challenges and opportunities for clinicians (both individually and collectively), policymakers and funders to adopt models of care that are aligned to the evidence to ensure the best outcomes for people with low back pain.

Physiotherapists have an opportunity to play a central role in the implementation of the standard and in the provision of best practice care for people with low back pain.

This article is an abridged version of a joint editorial that will be published in the scientific journals of the professions that manage low back pain in Australia, including the Journal of Physiotherapy.

The authors would like to acknowledge Dr Mary O’Keeffe (the University of Sydney), Dr Nardia Klem (Curtin University) and Associate Professor Ben Darlow (the University of Otago) for their contribution to the Low Back Pain Clinical Care Standard’s Quick guide for physiotherapists.

Download the Quick Guide for Physiotherapists. 

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

>> Professor Peter O’Sullivan FACP is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2017), John Curtin Distinguished Professor in the School of Allied Health, Curtin University and a clinical director of Body Logic Physiotherapy, Perth.

References

1. Disease GBD, Injury I, Prevalence C. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388(10053):1545-602. doi: 10.1016/S0140-6736(16)31678-6. 
2. Arthritis and Osteoporosis Victoria. A problem worth solving. Elsternwick, Victoria: Arthritis and Osteoporosis Victoria., 2013. 
3. Buchbinder R, van Tulder M, Oberg B, et al. Low back pain: a call for action. Lancet 2018;391(10137):2384-88. doi: 10.1016/S0140-6736(18)30488-4. 
4. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018;391(10137):2368-83. doi: 10.1016/S0140-6736(18)30489-6. 
5. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet 2018;391(10137):2356-67. doi: 10.1016/S0140-6736(18)30480-X. 
6. Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain 
look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med 2020;54:79–86. doi:10.1136/bjsports-2018-099878. 
7. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet 2017;389(10070):736-47. doi: 10.1016/S0140-6736(16)30970-9. 
8. Chiarotto A, Solomon CG, Koes BW. Nonspecific Low Back Pain. New England Journal of Medicine 2022;386(18):1732-40. doi: 10.1056/NEJMcp2032396. 
9. Traeger AC, Qaseem A, McAuley JH. Low Back Pain. JAMA 2021;326(3):286. doi: 10.1001/jama.2020.19715. 
10. Zadro J, O’Keeffe M, Maher C, Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review. BMJ Open 2019;9:e032329. doi:10.1136/bmjopen-2019-032329..