An estimated 70-90% of Australians will experience low back pain at some stage in their lives, but many will receive care – including imaging, opioids and surgery – that is at odds with evidence-based guidelines. [REF: Australian Institute of Health and Welfare. Back problems, associated comorbidities and risk factors. Canberra: AIHW, 2016]
And it’s not just a local problem. In 2018, The Lancet published a series of articles calling for improved management globally.
To improve care, the Australian Commission on Safety and Quality in Health Care is developing a Low Back Pain Clinical Care Standard. The draft Standard was recently open for consultation and is expected to be finalised later this year.
Atlas findings
The urgent need for clinical guidance on low back pain management was reinforced last month with the release of the Fourth Australian Atlas of Healthcare Variation. The Atlas examines surgery for lumbar spinal decompression and lumbar spinal fusion. These surgical operations have a limited role in treating chronic low back pain (spinal surgery for treating infection, tumours, or injury, was excluded from examination in the Atlas).
The Atlas shows that in 2015–2018, the rate of hospitalisation for lumbar spinal fusion was 12.4 times as high in the area with the highest rate compared with the area with the lowest rate. For lumbar spinal decompression, the rate of hospitalisation in the area with the highest rates was 7.7 times the area with the lowest.
The Atlas did note, however, that there was a small decline (4%) in the number of lumbar spinal fusion procedures and a larger decline (25%) in the rate of lumbar spinal fusion excluding decompression between 2012–2015 and 2015–2018 (spinal fusion can be done on its own or with an accompanying decompression).
Over the same period, there was also a drop in hospitalisations (6%) for lumbar spinal decompression (excluding lumbar spinal fusions).
The Atlas calls for priority to be given to ‘examining and improving access to services that provide multidisciplinary review and non-surgical treatments for chronic low back pain’.
Draft Standard
The draft Low Back Pain Clinical Care Standard notes that most acute episodes of low back pain will improve on their own or within the resources of primary care management, without further investigation or referral to specialists.
Alice Bhasale, Director, Clinical Care Standards at the Commission, says the Standard emphasises simple, self-management messages to stay active and avoid bed rest, and increasing activity as the pain improves.
The Standard will help clinicians to support patients without prescribing opioids, she says.
‘As the pain cycle escalates, people take drugs but continue to have pain, then they end up taking a stronger medicine, which may be an opioid,’ Ms Bhasale says. ‘And this then just increases their risk of other adverse events.’
She says the draft Standard highlights a holistic, biopsychosocial model of pain, prompting clinicians to consider other factors known to increase the risk of progressing to a chronic problem, such as depression, a work-related injury or the person’s beliefs about pain, that may be contributing to ongoing low back pain.
For such patients, Ms Bhasale says, unnecessary imaging can foster unhelpful beliefs about the cause of their back pain, when reported findings are often normal degenerative changes that occur in many people without back pain.
Emergency presentations
Shifting entrenched clinical practices, as well as consumer expectations about the care they should receive for low back pain, will take time, says Dr Christopher Needs, a co-author on the Sydney Health Partners Emergency Department (SHaPED) trial.
Dr Needs, a Senior Rheumatologist at Royal Prince Alfred Hospital, says the SHaPED trial investigated a model of care developed by the Agency for Clinical Innovation to improve the management of back pain presentations in emergency departments.
People experiencing low back pain may present to EDs for several reasons, Dr Needs says.
‘The pain may be severe, causing the patient to become frightened about a loss of independence,’ he says.
And some patients turn to the ED when they feel that they are not ‘getting anywhere’ with their GP, Dr Needs adds.
‘Some people may come to the ED thinking that they can get a scan done quickly, believing, falsely, that having a scan will provide them with the answers to their pain.’
The key messages in the ACI model are: patients with non-serious low back pain do not require lumbar imaging; where medicines are used, simple analgesics should be the first option; and patients with non-serious low back pain should be managed as outpatients.
The model was rolled out at four NSW hospitals (Royal Prince Alfred, Canterbury and Concord Repatriation General Hospitals in Sydney, and Dubbo Base Hospital in regional NSW) during the trial.
The SHaPED trial involved a four-month education program for 269 emergency department clinicians across the four hospitals and examined 4625 episodes of care. All sites were then followed up for at least three months.
The trial results, which were published in The BMJ earlier this year [SUBS: MARCH], were mixed. Opioid use reduced over the study period, and clinicians’ beliefs about the management of low back pain in EDs improved. The impact on imaging use, however, was uncertain.
Ms Bhasale adds that care in emergency departments can compound issues for GPs, particularly if patients have an expectation that opioids intended for short-term pain relief in the ED are the gold standard treatment for their pain. ‘It’s really important for people to get consistent messages about pain management,’ she says.
Missed diagnosis fears
One barrier to reduced imaging use, Dr Needs says, is clinicians’ fear of a missed diagnosis.
‘One of the first things we do when assessing back pain is to try to rule out any serious pathology,’ he says. ‘Generally, you can do that with a good history and examination. Imaging is not needed most of the time.’
Patient demand for imaging is also a factor. Dr Needs says in patients without serious pathology, imaging is unlikely to provide answers about the cause of back pain, and it may also trigger anxiety for patients where there are unrelated, insignificant radiographic findings.
He says initiatives like the SHaPED trial, as well as the upcoming release of the Low Back Pain Clinical Care Standard, will help to boost clinicians’ confidence in managing low back pain without ordering imaging.
Also, he says, efforts to follow-up patients with low back pain until the resolution of their pain, will improve care and reduce the risk of missed diagnoses.
‘It’s important to have a safety net there so that people aren’t just seen once; they are monitored until they do improve.’