can primary care provide effective management of chronic pain?

Aberdeen Pain Research Collaboration

Epidemiology Group, Department of Public Health

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

Lifetime prevalence of back pain

Papageorgiou et al, 1995Population: 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+

Pre

vale

nce

(%

) Lifetime prevalence

1-year prevalence

1-year consultation

Consulting for LBP

Consultation pattern

% c

onsu

lters

• Most persons consult once only

• Consultation more than three months after initial consultation is very rare

Consulting for LBP

Time since consultation

% c

onsu

lters

• 25% consulters are symptom free one year later

• 50% have pain and disability

Pain and Disability

Symptom free

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

Environment

0

10

20

30

40

50

60

70

80

I/IIProfessional

IIINon-Manual

IIIManual

IV/VNon-Skilled

Pre

vale

nce

(%)

Palmer et al, 2000

Social class

Environment

Obesity

Lack of exercise

Cigarette smoking

Lifestyle

EnvironmentWorkplace:

Mechanical factors

Mechanical (injury)

EnvironmentWorkplace:

Psychosocial factors

Psychosocial factors in the workplace

• 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

0

10

20

30

40

50

60

70

80

0 - 2 3 4 5 - 6

% w

ith

bac

k p

ain

at

3 m

on

ths

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)

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?

Environmental factors

• 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

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

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

Other therapies

• 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

-5

-4

-3

-2

-1

0

1

2

3

4

5

Baseline 2 6 12 months

Ch

ang

e: R

ola

nd

an

d M

orr

is D

isab

ilit

y Q

u.

Advice

Physiotherapy

Lancet 2005; 365:2024

Pain management(n = 201)

Manual Physiotherapy(n = 201)

Completely/much better (%)

68

Satisfaction withtreatment (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 carePsychosocial interventions

Rol

and

and

Mor

ris

Dis

abil

ity

Ro

lan

d a

nd

Mor

ris

Dis

abi

lity

Sco

re C

ha

nge

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

Pai

n (V

as)

Cha

nge

Sco

re

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

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

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

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

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”

Back Beliefs: Population-level

Before During After 3 years later

Victoria 26.5 28.4 29.7 28.8

NSW 26.3 26.2 26.3 26.1

Back Pain Beliefs Questionnaire

Intervention

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

Sub-grouping for Targeted Treatmentin 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]

The STarT Back Approach

“Identify subgroups by screening for prognostic indicators that can be

targeted with available treatment options”

Primary Care Context:

Problems Solutions

Diagnosis is difficult Prognostic assessment is possible

Treatment modifiable prognostic indicators are identified too late

Early targeted intervention before problems become entrenched

Treatment provision is inconsistent A systematic approach to treatment

Available treatment options

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)

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.

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)

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

Johnson et al, 2007 Spine (in press)

-30

-20

-10

0

10

20

30

3 6 9 12 15

Group Sessions better

Usual Care betterPai

n (V

as)

Cha

nge

Sco

re

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