Australian physiotherapists help write new national clinical care standard on low back pain

Australian Physiotherapy Association endorsement

While the standard stresses that it is vital to rule our ‘serious pathology’ as a cause of LBP, it points out that issues such as malignancy or vertebral fracture comprise less than 1 per cent of cases in primary care settings.

The standard, which is endorsed by the Australian Physiotherapy Association among 16 other professional and consumer bodies, states that using a biopsychosocial model in assessing and managing LBP – without a specific nociceptive source – has been consistently recommended by researchers.

‘Improved education and training in this model for assessing and managing low back pain are crucial to reducing unnecessary investigations and treatment, and improving patient outcomes.’

Obstacles outlined

The standard acknowledges that a variety of long-standing issues could hamper attempts to implement the evidence-based recommendations set out in the standard. Some of them – such as short appointment sessions in primary care settings – will be familiar to UK-based physiotherapists.

Reported barriers include

• current models of healthcare reimbursement, short consultation times in primary care
• low awareness or uptake of clinical guidelines, physician misconceptions about best care
• fear of litigation if serious pathology is missed, patient expectations
• long wait times, lack of access to, and availability of, support services for self-management
• lack of access to, and availability of, specialised effective interventions

Support self-management

On a more positive, the standard notes: ‘Implementing this clinical care standard and integration with other efforts to improve the management of low back pain across the health sector will be vital to addressing some of these issues and achieving better outcomes.’

Another issue that has dogged attempts to improve attempts to improve treatment outcomes in the UK – ‘low health literacy’ – receives attention in the Australian document. ‘Low health literacy is a risk factor for poor health outcomes. Chronic, disabling low back pain disproportionately affects people with low income and limited education.

‘Awareness of how patients’ health literacy levels influence their ability to seek, understand and apply health information can assist clinicians to tailor patient education and communication to support self-management,’ the standard states.

The standard also notes that issues such as the ‘overuse’ of imaging and opioid medicines in the assessment and treatment people with LBP , and the ‘underuse’ of advice and information, have been raised by researchers in Australia and other countries in the past.

Implementing this clinical care standard and integration with other efforts to improve the management of low back pain across the health sector will be vital to ... achieving better outcomes

'Stay active' advice 

Elsewhere, physios and other clinicians are advised to encourage patients to stay active and to consider the importance of returning to work. The standard is peppered with examples of statements practitioners can use in such circumstances, such as the following

Explain to the patient why staying active is important (example)

‘The pain does not mean you are undergoing serious damage. Remember that your back is strong. Movements may be painful at first, like an ankle sprain, but they will get better as you gradually get active again. It is likely that you will experience some pain with activity, but that does not mean that your back is getting worse or that your spine is damaged.’

Advise the patient on the importance of continuing or returning to work (example)

‘Staying at or getting back to work as you are able, even part-time at first, will also help you recover. By working together with your employer and healthcare team, you are more likely to recover and avoid the problems associated with taking a lot of time off work.’

Key practice points

• exercise programmes should be individualised, taking into account the patient’s physical activity preferences, beliefs and specific functional impairments
• exercise programmes should include stretching, strengthening and aerobic exercises that are functionally oriented
• start with gentle movements (water-based walking, land-based walking, gentle swimming and floor stretches that encourage the spine to move within normal planes (activity should be graded by the duration of time spent exercising, rather than the pain experienced)
• as the patient’s tolerance to activity over longer periods increases, the mode, frequency and/or intensity of activity can be progressed
• functional exercises can be introduced to encourage activation of large muscle groups (squats, lunges and step-ups)
• exercise that patients enjoy (yoga, Pilates, walking and cycling) can be gradually introduced 
• in the later stages of rehabilitation, more dynamic and higher-load exercises can be performed

Healthcare providers are told they should ensure that patients have access to a range of support options, such as telehealth. ‘Ensure that systems, processes and appropriate resources are in place so that adults with low back pain can access the physical and psychosocial clinical services they need.'

The standard adds: ‘Identify where access issues are likely barriers to appropriate treatment and develop strategies to address them (such as telehealth).'

Factfile

• roughly one Australian in six reports having a back problem, including a range of musculoskeletal (MSK) conditions related to the back
• low back pain is the most common type and contributes significantly to the burden of back problems and MSK pain (in Australia and globally)
• the ‘burden’ is increasing and is expected to continue to increase as the population ‘ages’
• back problems are the second most common reason Australians seek care from their GP, and are a leading cause of visits to emergency departments in Australia and throughout the world

To see the standard in full, visit: https://www.safetyandquality.gov.au/standards/clinical-care-standards/low-back-pain-clinical-care-standard

To watch the launch video, visit: https://safetyandquality.tv/live/

Twitter: @PeteOSullivanPT