It’s one of the hottest issues in musculoskeletal physical therapy. How do you take all the complicated factors affecting low back pain and combine that knowledge to get the right treatment to the right patient?
Back pain is complex but the answer is getting clearer according to Peter O’Sullivan, Professor of Musculoskeletal Physiotherapy at Curtin University, Perth, and one of the most influential and innovative names in the specialty. You create systems which help physical therapists sort through the multiple layers of a person’s presentation, so that they can identify the interventions most likely to bring about significant change in that individual.
Such systems, known as stratified models, are becoming according to Nadine Foster, Professor of Musculoskeletal Health in Primary Care at Keele University in the UK, one of the most talked about areas in physical therapy research and clinical practice. So it’s not surprising that they are the subject of a major session at the World Confederation for Physical Therapy’s Congress to be held in Singapore in May – chaired by Foster and featuring O’Sullivan as a main speaker.
O’Sullivan’s own particular stratified care model, called classification based cognitive functional therapy, has been highly influential on many physical therapists managing complex pain disorders since it was announced to the world nearly a decade ago. Acknowledging the complex foundations of pain, it integrates targeted cognitive strategies with functional rehabilitation.
“It’s about empowering the clinician to deal with the person as they present when they walk through the door,” says O’Sullivan, who has given over 80 keynote addresses at national and international conferences presenting his work and has conducted clinical workshops in over 22 countries.
“When we talk to clinicians about persistent and disabling back pain, they can throw up their hands and say ‘Don’t send that patient to me!’ What that highlights is that there are so many complicating factors that they don’t feel confident to deliver targeted treatment. But what we find is that, when we help them to understand pain from these different perspectives, give them the skills to identify the factors and then empower them to be targeted in their management, many of these quite disabling disorders can change quite quickly.
O’Sullivan contends that traditional ideas that low back pain can be directly related to structural damage or degenerative changes are too simplistic: spinal imaging shows that damage does not necessarily equate to pain. Clinicians need to look more deeply into the patient’s history, beliefs and behaviour.
“Back pain is more complicated than people would like to think. What predicts disability is not necessarily what you see on a scan – it may be your response to what you see on the scan, or how fearful you are about pain, or whether you have a history of depressed mood or anxiety. We also know that there are all kinds of central nervous changes that result from pain over extended periods, and that people suffering from pain change their behaviours in ways that are probably unhelpful and feed into the cycle.”
“So when someone presents in a clinical setting, we’ve got a whole load of factors to wade through, and we have to find ways of sorting them, to get to the bottom of what factors are important for that person at that time.”
“Currently, there are a lot of systems being used to do this. Physical therapists traditionally look at signs and symptoms, based on the belief that this is all about structure. But systems need to take account of the fact that there are other factors too. You need an integrated approach of sorting through the multiple layers of a personal presentation.”
Nadine Foster says that such stratified approaches are fast becoming the dominant school of thought in research and clinical practice, and are important because they are about basing treatment decisions on solid evidence rather than opinion. Her session at the WCPT Congress will examine three approaches to stratified care which show benefits for low back pain patients, and the evidence supporting each.
Among the speakers will be Jonathan Hill from the Musculoskeletal Clinical Trials Unit at Keele University, who helped develop the STarT Back screening tool for low back pain. Trials of the tool, reported in The Lancet, demonstrated favourable outcomes for patients when a stratified care approach based on prognosis was adopted.
Also speaking will be: John Childs, Associate Professor in the US Army-Baylor University Doctoral Program in Physical Therapy, who has pioneered stratified care based on treatment responsiveness; and Mark Hancock, Senior Lecturer at Macquarie University, Sydney, who has extensively researched ways of identifying subgroups of low back pain patients who respond best to specific interventions .
“Peter O’Sullivan has worked very hard on one of the first mechanisms for stratifying care, and we want to look at other models which have built on this,” says Nadine Foster. “Which approach you take might depend on which setting or country you work in – there’s no one way to good patient care. ”
“So what’s going to be really constructive about this session at the WCPT Congress is that we can get people from a wide range of countries together, and compare and contrast the different models. It will help physical therapists move forward in treating low back pain and build a basis for future collaborations and research.”
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