can primary care provide effective management of chronic pain?
DESCRIPTION
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.ukTRANSCRIPT
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