Easing tension about headache and migraine

Delivering the Australian Pain Society’s pre-conference physiotherapy workshop, sponsored by the APA, Dr Alicia Rayner FACP explored physiotherapy management of tension-type headache and migraine.

Alicia laid down a challenge to physiotherapists—reconsider how you are assessing and managing tension-type headaches and migraines. 

These conditions, Alicia said, are often viewed in silos, as either purely musculoskeletal or purely medical, when in reality they frequently present as persistent pain conditions with significant overlap. 

The message from the Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2022) is clear—physiotherapists have a crucial role to play in identifying, understanding and managing primary headaches, particularly when viewed through a pain science and central sensitisation lens.

Alicia encouraged clinicians to see both tension-type headaches and migraines as primary headaches, underpinned by a sensitised nervous system. 

These conditions share many features with other nociplastic pain presentations such as fibromyalgia or irritable bowel syndrome and benefit from an approach that extends beyond joint or soft tissue treatment, she said. 

Migraines, for instance, often involve widespread sensory hypersensitivity, disrupted sleep, fatigue and cognitive difficulty—hallmarks of central sensitisation that physiotherapists are well placed to address.

Among the tools available to physiotherapists, Alicia highlighted exercise as one of the most effective and underutilised interventions. 

She pointed to research recommending three sessions of moderate-intensity exercise per week to reduce migraine frequency and intensity. 

Exercise not only activates the endogenous pain inhibition system but also improves sleep, mood and overall wellbeing. 

Dr Alicia Rayner.

For those with sensitised systems, Alicia said, graded exposure is recommended, along with patient-led pacing to avoid flare-ups and build confidence in moving.

Manual therapy also has a role, Alicia said, particularly in treating tension-type headaches, which make up the bulk of primary headache presentations. 

These are typically bilateral, mild to moderate in intensity and not aggravated by physical activity. 

Alicia said that many patients misclassify their headache type, often attributing their pain to cervicogenic sources, when in fact their symptoms align more closely with tension-type headache or migraine. 

In these cases, manual therapy may reduce musculoskeletal input and stress-related tension, offering relief even if it’s not addressing a biomechanical cause directly.

Alicia also addressed the complex relationship between migraine and neck pain. While neck pain may accompany migraine, Alicia urged clinicians to be cautious about assuming causality. 

‘Cervicogenic headache is rare,’ Alicia says. ‘But we often treat the neck and the headache improves, leading us to draw conclusions that may not be accurate.’ 

Instead, she encouraged clinicians to view neck pain as one of many symptoms of central sensitisation rather than a driver of headache in most cases.

Alicia provided practical tools for diagnosis, including the FLINDA (Frequency, Location, Intensity, Nature, Duration and Autonomic signs) (coined by Alastair Flett) framework. 

This structured questioning helps clinicians uncover patterns and characteristics that differentiate tension-type headaches from migraines and supports more accurate diagnosis. 

This is especially important because patients often under-report or misclassify their symptoms. She said that a migraine does not have to be severe or unilateral to meet diagnostic criteria. 

Moderate bilateral headaches with nausea and sensory sensitivity may still qualify.

In discussing common triggers, Alicia introduced the DEEPH (Dietary, Emotional, Environmental, Physical, and Hormonal) (devised by Alastair Flett) method, highlighting the multifactorial nature of headache and migraine. 

Patients with migraine often experience a cyclical sensitivity to stimuli, which can be modulated through lifestyle education and support. 

Alicia stressed the importance of helping patients recognise patterns in their symptoms, reinforcing the therapeutic value of headache diaries and self-monitoring.

Alicia emphasised the need to rule out red flags, including signs of vascular events or medication overuse headache or significant changes in headache presentation during pregnancy. 

New or worsening headaches should always prompt further investigation, she said. 

Once serious pathology is excluded, physiotherapists are well positioned to lead conservative, non-pharmacological care for these patients.

Treating primary headache, Alicia said, isn’t about curing a condition. It’s about helping people live better with it. 

Through education, movement and an understanding of pain mechanisms, physiotherapists can provide meaningful support.

‘We’re not just treating the headache,’ Alicia said. ‘We’re helping patients understand their condition, feel empowered and regain control over their lives.’

Equity in pain research

Dr Emma Karran spotlighted urgent equity gaps in pain research, introducing a globally developed dataset designed to draw attention to disparities.

Tackling the persistent under-representation of marginalised groups in pain research, Dr Emma Karran argued that inequities in pain outcomes often remain invisible due to incomplete or superficial collection of sociodemographic data. 

To address this, she led a major international project designed to identify which equity-relevant data should be collected.

Emma, a senior research fellow from the University of South Australia with a background in physiotherapy, education and research into the social determinants of health, made the case that pain research often fails to account for the broad societal and contextual factors that influence pain experiences and treatment outcomes. 

Traditional data collection tends to prioritise basic descriptors such as age, sex and education, often conflating gender and sex and omitting key details such as place of residence, cultural identity or financial security.

Emma explained that this narrow scope can obscure meaningful differences in how pain is experienced and managed across different populations.

To build a more equitable evidence base, Emma and her team launched a three-year pain research project, ‘Identifying Social factors that Stratify Health Opportunities and Outcomes (ISSHOOs) in pain research’. 

The project aims to produce global consensus on a standardised, equity-relevant dataset for inclusion in all human adult pain studies. 

The dataset will help researchers more accurately describe study populations and interpret findings through a health equity lens.

The ISSHOOs project unfolded in several stages. It began with two scoping reviews examining how social determinants of health are currently captured in both clinical and research settings. 

Dr Emma Karran.

The findings were mapped against the PROGRESS-Plus framework—a tool widely recognised in health equity research. This provided the foundational categories for the subsequent consensus process.

A three-round Delphi study followed, enlisting 168 global participants including pain researchers, clinicians, equity experts and individuals with lived experience of persistent pain. 

More than one-third of participants had firsthand experience with chronic pain, underscoring the project’s commitment to inclusivity. 

The Delphi process invited these contributors to evaluate, suggest and prioritise items for inclusion in a minimum dataset.

Despite the careful design of this consensus process, Emma acknowledged a key limitation. 

Certain groups—such as people from lower socio-economic backgrounds, rural communities and minoritised cultural or sexual identities—were under-represented. 

To counter this, the team conducted targeted supplementary data collection, recruiting 55 additional participants from historically under-represented groups. This ensured that the dataset was more reflective of diversity often missing from pain research.

The final consensus process, Emma said, identified two datasets. 

Set A, the minimum dataset, includes eight items: age, sex, gender, place of residence, race/ethnicity/culture, education level, financial status and work status. These items (each including a question and a set of response options) are considered essential for describing study participants in a way that supports equity-focused interpretation and application of research findings. 

Set B, the extended dataset, contains 30 optional items from which researchers can select a subset to suit their specific research questions and study context. These include housing conditions, health literacy, access to healthcare and experience of discrimination.

Emma emphasised that the datasets are not intended as rigid templates but as adaptable tools that can guide culturally sensitive research. 

Each item is accompanied by preambles for participants and detailed instructions for researchers to ensure clarity, appropriateness
and transparency in data collection. 

For example, Emma said, sex and gender are explained simply but respectfully, taking into account the diverse legal and cultural contexts in which research may occur.

Emma went on to outline the broader benefits of using this dataset. More comprehensive demographic data can support subgroup analysis, highlight treatment disparities and improve findings. 

Harmonised data also enables better comparisons across studies and contributes to systemic reviews with an equity lens. 

Emma said that Set B’s context-rich variables may help generate new hypotheses about how social environments influence pain and its management.

However, Emma was candid about the project’s limitations. While it offers a significant advance in standardising equity data in pain research, it does not directly address structural and systemic drivers of health inequity such as institutional racism or economic policy. 

The dataset’s relevance for paediatric populations is also limited at this stage because the complexities of adapting it for children require further investigation.

Despite this, Emma’s work provides a powerful blueprint for shifting how pain research is conceptualised and conducted. It invites researchers to engage more deeply with questions of who is studied, who is left out and how these choices shape the evidence base that informs clinical practice and policy.

As health equity continues to gain prominence across disciplines, this project is also a reminder that meaningful change begins with the basics—asking better questions, listening to more voices and collecting data that matters most. 

If pain researchers want to serve all people, their research must first see them.

Rural reality check

Chronic pain and access to pain care are not experienced equally across Australia. Physiotherapist and PhD candidate Sophie Shephard presented a powerful challenge to the ‘metrocentric’ assumptions embedded in pain policy.

Pain care in rural and remote Australia, Sophie Shephard MACP argued, is shaped by deeply entrenched systemic inequities that go beyond workforce shortages or geographic isolation. 

While 28 per cent of Australians live outside major cities, rural populations shoulder a disproportionate burden of disease, including significantly higher rates of chronic pain.

However, Sophie said, rural pain inequity cannot be solved by parachuting urban solutions into rural areas. 

Instead, she advocated for a systems-level understanding of pain management that recognises the influence of place, power and policy.

Central to Sophie’s presentation was the concept of ‘urbanormativity’—the tendency to view urban settings as the ideal model for healthcare delivery and rural settings as somehow lacking or backward. 

As a consequence, pain services, policies and even clinical research are predominantly shaped by urban norms, rendering rural voices invisible. 

This is compounded by what Sophie calls an ‘epistemic injustice’—a process by which rural people are devalued as knowers or excluded from the development or dissemination of knowledge that affects their care.

Sophie highlighted the importance of adopting a framework that allows for a nuanced understanding of rural health systems.

Sophie Shephard.

Drawing on a model by Lisa Bourke and colleagues in the 2012 paper Understanding rural and remote health: a framework for analysis in Australia, Sophie described five interrelated domains that shape rural health outcomes: geographic isolation, rural locale, local health responses, broader health systems and social structures, all underpinned by power. 

These domains interact to create a complex picture of rural health and pain care, where distance and infrastructure are just the beginning of the challenge. 

Social processes, expectations around participation in care, informal community-based health responses and the influence of political and economic structures all have a role to play, Sophie says.

Geographic isolation, for example, includes environmental barriers such as mountain ranges, flood zones or unsealed roads. 

Rural locales are socially shaped by tightly knit community networks and longstanding community knowledge—assets frequently ignored in urban-centric planning. 

Health services in these settings are often pieced together through formal and informal supports and yet these responses are rarely recognised or funded appropriately, she argued.

Broader health systems including state and federal policies, funding structures, professional standards and institutional priorities are often designed without meaningful rural input. 

These systems continue to reproduce inequities through omission and lack of insight, Sophie said. 

This was reinforced by preliminary findings from Sophie’s systematic review of chronic pain interventions, evaluated in rural Australian cohorts. 

Despite a search strategy designed to be as broad and inclusive as possible, the review identified only 10 studies, of which two genuinely focused on the rural context. 

Strikingly, all bar one failed to report individual participant place of residence, relying instead on the location of service delivery.

While this is not uncommon, Sophie said, it undermines any understanding of whether the interventions were truly accessible or appropriate for rural populations. 

Without data on participant residence, it is impossible to understand who is actually being reached—particularly in a health system as centralised as Australia’s, where service location alone tells us little about travel burden, accessibility or the extent to which rural communities are excluded in practice.

Compounding this invisibility, the reviewed studies also failed to report on other critical intersectional aspects of participant identity such as income, education level, cultural or linguistic background and Aboriginal or Torres Strait Islander background.

Sophie encouraged the audience to ‘problematise’ how rural pain management is typically framed. 

For example, while it is common to frame the problem of rural pain care as the result of a lack of trained workforce and resources to support best practice pain management, this assumes that metropolitan models of best practice are universally applicable. 

Reframing the problem—by asking instead whether urban models are fit for purpose in rural contexts—potentially leads to very different solutions. 

Sophie advocated for bottom-up, community-led approaches that are flexible, innovative and grounded in the local realities of rural life.

The shift in thinking is not just theoretical, Sophie said. It has real implications for how pain care is designed and delivered. 

She argued that even the most efficacious pain interventions may prove ineffective if they cannot adapt to the context in
which they are implemented. 

Pain, like health, is an emergent product of complex systems. Solutions that fail to account for local realities may ultimately fail the people they are designed to help.

Rural people are not passive recipients of care, Sophie argued, and nor should their communities be viewed through a deficit lens.

Instead, the pain sector must embrace a systems-based understanding of rural health that values lived experience, recognises the complexities of place and elevates local knowledge and leadership.

Springing into tendon talk

Physiotherapist and researcher Associate Professor Ebonie Rio delivered a compelling case for re-imagining how clinicians understand, assess and treat tendon pain.

Far from being passive cables that connect muscle to bone, tendons are metabolically active tissues with cells (tenocytes) that constantly communicate and remodel in response to load and their environment. 

Highlighting the capabilities of tendons, Ebonie Rio MACP, an APA Titled Sports and Exercise Physiotherapist, said that in the lower limbs especially, tendons act like springs, storing and releasing energy to power movement efficiently. 

Whether leaping in sport or simply stepping off a kerb, humans rely on the spring-like action of tendons throughout life.

Yet despite their critical function, tendons are vulnerable to injury and the consequences can be complex. 

Ebonie explained that tendon injury can affect a really broad group of people, from elite athletes to sedentary older adults, office workers and people with chronic illness such as diabetes and HIV. 

Despite this prevalence, Ebonie said, there is no specific International Classification of Diseases code for tendinopathy, making it difficult to track its true incidence or burden on the health system.

One of the central themes of Ebonie’s talk was the need to improve diagnostic clarity. 

Ebonie described four distinct categories of tendon injury: tendinopathy, peritendon irritation, bursitis and rupture. Each has a unique presentation, response to load and treatment pathway. 

For instance, while tendinopathy is driven by high-speed tensile loading, peritendon issues are provoked by movement and friction and bursae-related pain may be triggered by footwear or compression.

Understanding these differences, Ebonie said, is essential for delivering appropriate care.

Ebonie advocated for a move away from palpation and imaging as primary diagnostic tools. 

She noted that pain during tendon palpation is common but often unhelpful for distinguishing clinical diagnosis. 

Associate Professor Ebonie Rio.

Similarly, imaging frequently shows abnormalities in people without symptoms, which makes it an unreliable guide. Instead, she recommended a load-based functional assessment to determine whether pain is localised and increases in response to progressively challenging loading tasks—hallmarks of tendinopathy.

But the tendon story doesn’t end in the tissues. Ebonie delved into the central nervous system changes that accompany chronic tendon pain. 

People with tendinopathy exhibit alterations in the motor cortex, changes in excitability and inhibition, and asymmetries in strength and motor control.

These adaptations, she said, can pose a heavy cognitive burden, akin to pressing both the brake and the accelerator while trying to move. Yet other aspects of neural function, such as body schema and body modulation, appear to remain intact.

This brain–body link has significant implications for treatment. According to Ebonie, while current rehabilitation protocols often restore basic strength, they rarely challenge or retrain the motor cortex.

To truly optimise function and prevent recurrence, clinicians may consider how they integrate neuroscience—targeted methods that engage the brain during movement, she said.

One simple yet powerful tool Ebonie championed was externally paced strength training using a metronome. Patients concentrate and coordinate, promoting changes in cortical activity. 

Ebonie said that compared to unstructured, self-paced movements, externally paced exercises deliver both muscular and neural benefits.

Equally important is the language clinicians use. The words chosen in the clinical setting shape patients’ expectations, beliefs and engagement with treatment. 

Outdated or nocebic terms such as ‘tendonitis’ or ‘degenerative tendon’ imply inflammation or damage, fuelling fear and passivity, Ebonie argued. 

More accurate terminology such as ‘tendinopathy’ helps frame the condition as a load-related issue that improves with active rehabilitation.

Ebonie set out a clear hierarchy of intervention effectiveness. Passive therapies, she said, consistently underperform. 

Effective treatment requires building sufficient muscular capacity and motor control through targeted loading, with education and reassurance to reduce fear and build confidence.

She also encouraged clinicians to tailor interventions to the individual and their specific tendon injury. For example, people with gluteal tendinopathy benefit from reducing compression by avoiding crossed legs or prolonged standing on one hip. 

Individuals with Achilles insertion issues need to avoid stretching and instead benefit from heel lifts or load modification.

Bursae-related pain (for example, the superficial bursae) is often improved by changing footwear or reducing the friction or compression from shoes.

Ebonie also touched on the increased incidence of tendon rupture following the COVID-19 pandemic, theorising that changes in physical activity patterns may have played a role. 

Tendons that rupture usually have underlying pathology but no pain and these changes in behaviour combined with asymptomatic changes may have contributed to the post-pandemic spike, she said.

Ebonie concluded by urging clinicians to embrace a more nuanced and responsive approach to tendon care. 

She emphasised the importance of accurate language, load management tailored to the individual and rehabilitation that addresses strength and motor control and central nervous system adaptation.

By shifting focus from damage and dysfunction to capability and adaptability, practitioners can help patients better understand their condition, engage more confidently with treatment and, ultimately, return to the activities that matter to them.

Staying strong with arthritis care

A strengths-based approach to arthritis and persistent pain in the Aboriginal and Torres Strait Islander population was the focus of a talk by physiotherapist researchers Dr Samantha Bunzli and Jane Linton.

A presentation by Dr Samantha Bunzli APAM and Jane Linton (Gumbaynggirr) called on physiotherapists to reframe how healthcare systems engage with chronic musculoskeletal pain, particularly in Aboriginal and Torres Strait Islander populations. 

As part of a program entitled ‘Strengthening pain care with our ways’, Samantha and Jane were members of a research team that advocated for harmonising different paradigms of health. 

Where Western medicine traditionally focuses on pathology and deficit (what makes people sick), Aboriginal and Torres Strait Islander approaches are rooted in salutogenesis—understanding and fostering the conditions that enable individuals and Communities to live well.

Dr Samantha Bunzli.

Samantha and Jane began with a video story of Thomas, a former football player living with osteoarthritis whose wellbeing was sustained with regular exercise, cultural connection and social participation. 

His experience underscored the concept of ‘flourishing’—a holistic view of health as more than the absence of disease. 

Samantha and Jane described it as a framework that closely aligns with Aboriginal and Torres Strait Islander views on wellness, where cultural identity, Community belonging and connection to Country are critical to managing pain and chronic illness.

This perspective is especially pertinent for physiotherapists, whose scope of practice includes physical rehabilitation, health education and promoting functional independence. 

Samantha and Jane encourage clinicians to look beyond joint function and physical impairment and consider broader health indicators such as social, emotional and cultural wellbeing. 

They presented a powerful visual metaphor: the melaleuca tree. The tree and its flowers are culturally significant for some Aboriginal Communities. 

In their model the tree’s roots represent culture, Country and kinship; its soil signifies historical and systemic influences such as racism and colonialism and the branches are the social determinants of health—housing, employment and access to healthcare.

When those conditions are supported, the tree flowers, symbolising a life that flourishes.

Physiotherapists, they argued, are well positioned to support this flourishing by working in partnership with Aboriginal and Torres Strait Islander Communities to provide culturally safe and accessible care. 

However, access to physiotherapy and other non-pharmaceutical interventions remains inequitable. 

The research team conducted a systemic review showing that Aboriginal and Torres Strait Islander people are 1.5 times more likely to experience arthritis than other Australians, yet significantly less likely to access primary care services or receive joint replacement surgery. They are, however, twice as likely to be prescribed opioids for pain.

Rather than reinforcing a deficit discourse that frames Aboriginal and Torres Strait Islander communities in terms of disadvantage, the team applied a strengths-based model that centres Aboriginal and Torres Strait Islander voices and capacities. 

Through the ‘Stay Moving, Stay Strong’ project they established Community reference groups in Western Australia and Victoria to co-design arthritis education materials.

Aboriginal people living with arthritis shaped every aspect of the project, from identifying priorities to reviewing content, ensuring that the resources were culturally relevant, visually engaging and practically useful.

Key themes that emerged from interviews with 31 participants, who experienced all types of arthritis, included the social and emotional toll of arthritis, the importance of Community connection and barriers to accessing care. 

Participants expressed a strong desire for information that acknowledged their cultural context and responsibilities such as caring for family and maintaining cultural practices. 

The preferred formats for learning, Samantha and Jane said, were brochures and videos featuring artwork and stories from Aboriginal artists and Community members.

Jane Linton.

The project culminated in a suite of educational resources for osteoarthritis, rheumatoid arthritis, gout and lupus. 

The materials were co-designed using accessible language, balanced visual and written content and included links to local Aboriginal medical services. 

A dedicated website hosts four brochures and six videos showcasing lived experiences and personal strategies for managing arthritis. Samantha and Jane said that the response has been overwhelmingly positive.

Evaluation of the program is ongoing, with recent Community feedback affirming the relatability, usefulness and accessibility of the resources.

Suggestions for future iterations, Samantha and Jane said, include creating resources specifically for carers and family members, recognising the interdependence of individuals and their Communities in Aboriginal cultures.

The team’s work advocates for a shift in practice towards collaborative, culturally safe and Community-driven approaches that support Aboriginal and Torres Strait Islander people to thrive on their own terms. 

By embracing Aboriginal and Torres Strait Islander Community ways of knowing, being and doing, healthcare can become more inclusive, more effective and more connected to the people it serves.

This research, argued Samantha and Jane, stands as a compelling example of how researchers can contribute to social justice and health equity, not only by treating pain but by transforming the systems and assumptions that shape care.

The Staying Moving, Staying Strong project was conducted by a national interprofessional team of Aboriginal and non-Aboriginal health professionals and research leaders. 

In addition to Jane and Samantha, the research team involved Ngiyampaa woman Brooke Conley; Badimaya, Wajarri, Wilunyu woman Charmaine Green; Ngoonooru Wajarri woman Wanda Flanagan; Whadjuk, Balladong, Gnarla Karla Boodja Nyoongar man Trevor Pickett; Noongar (Wardandi) man Jonathan Bullen; Ivan Lin; Penny O’Brien; and Jennifer Persaud. The project was funded by an Arthritis Australia and Commonwealth Government grant, administered through Arthritis and Osteoporosis WA.

Driving change in low back pain care

Physiotherapist researcher Dr Nathalia Costa investigated systemic barriers and opportunities to improve low back pain care in Australia.

During her postdoctoral research at the Leeder Centre for Health Policy, Economics and Data at the University of Sydney, Dr Nathalia Costa (now a senior research fellow at the University of Queensland) and her team conducted a qualitative study to explore the perspectives of policymakers, academics, professional association leaders and other key stakeholders on what hinders low back pain (LBP) care in Australia and how to improve it. 

They used a systems thinking approach—a method that helps make sense of complex problems by examining how different factors and systems interact.

The results, based on 37 in-depth interviews, showed that LBP is a ‘wicked problem’ shaped by a web of challenges in a complex system. They also indicated some practical steps that could help to improve care.

A central finding from Nathalia’s work is the significant variability in care pathways for patients with low back pain. 

People receive inconsistent messaging from healthcare professionals, a reflection of divergent clinical philosophies, differences in training and differing care models across private and public settings. 

This contributes to confusion, mismanagement and uneven health outcomes, particularly in rural and regional areas and for those unable to afford out-of-pocket care.

Funding models also emerged as a major theme. Nathalia and her team’s research showed that the current Medicare fee-for-service model does not adequately support best-practice care. 

While guidelines advocate for non-pharmacological and non-surgical approaches, these are poorly funded or entirely unfunded.

Nathalia said that allied health services, which are often central to evidence-based care, remain under-supported, with limitations such as the five-session cap under chronic disease management plans.

Public understanding of LBP is another critical barrier. The interviews revealed widespread misconceptions including a desire for quick fixes, beliefs that movement can damage the spine and reliance on imaging and medication as primary solutions. 

The community struggles to navigate a fragmented health system; many consumers are unclear about the roles of different allied health professionals and how to access appropriate care.

Nathalia drew attention to the commercial and systemic forces that reinforce the status quo.

Dr Nathalia Costa.

Financial incentives encourage practices that may be low value or even harmful, such as over-reliance on imaging or passive treatment modalities. 

Especially in the private sector, time pressures and financial incentives make it difficult for clinicians to pursue ongoing education or shift to more evidence-based models of care. 

Interviewees highlighted that some practitioners engage in services not aligned with best practice to meet financial needs and one of them admitted doing this themselves.

Beyond these core challenges, Nathalia’s analysis points to a range of contributing factors that complicate efforts to improve care.

These include limited access to conservative management, short consultation times, siloed professional practice, persistent stigma around pain and the neglect of social determinants of health. 

Many of these barriers are entrenched in broader healthcare structures and policy inertia.

Interviewees also recommended changes to funding mechanisms such as expanding subsidies for allied health, funding multidisciplinary community-based care and restricting Medicare to better align with chronic disease needs. 

Public health campaigns to improve health literacy and reframe community perceptions of back pain were considered essential, Nathalia said.

Other proposals included reforms to the workers compensation sector, more robust information systems and improved workforce training to equip practitioners with the skills needed to deliver guideline-informed care.

A key takeaway is that how we define the problem of LBP influences the solutions that we pursue. Too often, LBP is framed narrowly as a condition to be managed at an individual level. 

Nathalia advocates for a broader, more inclusive framing, one that embraces complexity, priorities equity and recognises that coherent action across the system is more critical than pinpointing a single solution.

Despite this daunting landscape, Nathalia’s presentation offered a road map for progress. 

Her interviews revealed strong support for increased collaboration across stakeholder groups. 

People with lived experience and the community more broadly, clinicians, researchers, advocacy groups, professional associations, academics, universities, private health insurance companies, employers/workplaces, policymakers, government agencies, departments of health, research funding bodies, lawyers, advisory committees, the pharmaceutical industry and the compensation sector all need to engage in joint problem-solving to address the systemic nature of the issue. 

Practical suggestions included the creation of summits or working groups to facilitate cross-sector dialogue and the co-design of reforms.

Nathalia’s closing message emphasised the need for research and advocacy that extends beyond traditional academic boundaries.

By drawing on stakeholder analysis and cross-sector networks, researchers and clinicians can help monitor government accountability and drive meaningful change. 

As she noted, solving ‘wicked problems’ like LBP is not about finding one correct answer but about supporting stakeholders to work together towards coherent and sustainable action.

Watch video interviews with the researchers here.