NeuRAtalks Associate Professor James McAuley – Acute Low Back Pain

NeuRAtalks Associate Professor James McAuley – Acute Low Back Pain


well thank you very much and thank you
very much for inviting me to come and talk to you today about some of the work
that I’ve been doing over the last I guess 10 years or so since I arrived in
Australia from the UK to finish my PhD. I’m going to talk to you about some
work that we’ve been doing for acute low back pain and then we’ll hopefully
be able to answer the question of what have the guidelines done
for us. The reason we’re asking that question
really is because much of the work that I’ve been doing has been directed
towards trying to understand a little bit clearer about what the guidelines
suggest and whether or not there’s evidence for those suggestions and
whether there’s anything that we can improve on guidelines. Okay let’s get
started okay just so that we all know that we’re
talking about the same thing I know you will know this already but
today we’re talking about low back pain and low back pain for me is pain that lasts for longer than 24 hours
and for at least 24 hours and less than six weeks. If there’s a period
before that the onset of pain of at least a month pain free then we call
this a new episode of acute low back pain. That’s a pretty standard terms I’m
sure you’re all familiar with them but just to make sure that we’re talking
about the same type of back pain. Obviously also it’s bounded by the
material for the bottom of the gluteal fold and the bottom of the 12th rib any
pain that comes from that area – it can also go down the leg as well, but we’re
really not talking about sciatica or pain that has neurological symptoms we
think about that as something a little bit different or indeed pain that is
associated with a serious spine pathology. We did some work a few years ago out in
Western Sydney when we recruited a thousand patients who just developed an
acute episode of low back pain and went to see their primary care clinician and
we tried to investigate to try to identify any serious spinal pathologies
as a reason for their back pain consultation and we
found very few serious spinal pathologies in fact we couldn’t find any
cancer in 1200 patients mostly we found fracture we found 11 fractures so so
we’d say that serious spinal pathology as a cause of the first consultation for
low back pain for acute low back pain is pretty rare accounting for less than 1%
neurological symptoms accounts for about 5% 4 or 5% so this presentation will be
about the other 95 percent of people who have nonspecific low back pain it’s
pretty horrible term nevertheless it’s the one that we have for people who
don’t have there’s no structural cause that we can identify reliably that’s a
cause of their symptoms okay so what else about back pain well of course
there’s a major cause of work disability and work lost disability and work loss
now we know that how do we know that well this is one of the charts that’s
produced by the global burden of disease study and they produced these every
every few years this is the latest one that was published in The Lancet and you
can see a map of the world and you can see the colors and other colors across
the map of the world and purple represents the countries in the world in
which back pain has the biggest impact so it’s that in which the back pain has
is the biggest cause of disability now most of the world there you see is
covered in purple there’s only a few countries that are not in southern
Africa it’s hiv/aids in China it’s actually a hearing loss and in Central
America kind of Central America yeah it’s a neck pain so back pain is the
biggest cause of disability worldwide and in 2016 that accounted for 57 point
6 million days of sorry years years lost disability what does that mean that
means that for every person who had back pain and was disabled by that pain for a
few days of 2 days 3 days a week a month a whole year that was added up by the
global burden of disease and estimated to be equivalent to 50
than over 57 million days of years lost to disability in 2016 alone so it’s an
enormous problem as you can see worldwide what does that mean for the
individual well we also have some great date on that as well from from Deborah
Schofield and her team at the University of Sydney this has done some really
beautiful work trying to understand what actually happens to the economic impact
of back pain or on individuals and also the implication of that broader for the
rest of the for the rest of Australia and she focused on the age group of 45
to 64 because that’s where back pain is most common and it’s also where people
begin to think if they have back pain and that’s not getting any better than
then they may take early retirement from work and the fact back pain is the
number one reason for health-related early retirement so it’s a number one
reason that people retire early for those people for people who actually
stay and work up until they’re age 65 so they remain at work at Schofield and her
team estimated that they accumulate wealth and the amount of wealth of they
accumulate the median is two hundred and fourteen thousand dollars so by the time
we retire the median amount of the median amount of wealth that you will
accumulate is 214 dollars if you have back pain and you retire early that
comes down to three just over three three and a half thousand dollars now
obviously that’s a substantial difference so it’s back pain is the
leading cause of not only the leading cause of health retirement but it’s also
the leading cause of income poverty for those who retire early due to a health
condition if we take that a little bit further we think what does that cost to
the GDP well it reduces income it also reduces taxation of available to the
economy and also to include increases welfare costs in 2015 that was
estimated to be – a hit to the to the GDP of ten and a half billion dollars
and in 2013 is projected to rise to fourteen point five billion dollars
obviously these are staggering amounts that really could be put to better use
okay now what do we do about it so it’s a big problems a worldwide problem has a
massive economic and personal impact in Australia what do we do about it well of
course there are many clinical trials that have investigated different types
of treatments for back pain and is actually without doing a systematic
review of those it’s quite difficult to get a good number of those a good sense
of how many there are lots of people always talk about their increase the
numbers of trials are increasing but I just looked at this this morning this is
the Pedro is the is a search engine on off clinical trials related to
physiotherapy so physiotherapy so all types of physiotherapy fact it’s
interesting physiotherapist seem to be very organised in Australia they had
some brilliant researchers some of the top researchers in the world or in
Australia but physiotherapists seem to be doing very well in terms of getting
evidence together and this is a really great initiative which is run by a
couple of physiotherapy physical therapists so you can search
this this engine so they log every trial that’s a treatment for any to any type
of physiotherapy and then you can search it and I did that this morning and found
2,000 clinical trials for back pain and since 2003 3 when this evidence database
was established there have been 2 to over 2,000 clinical trials in low back
pain there we also have been over five hundred and ninety-ninth systematic
reviews that have led to 448 clinical practice guidelines I mean obviously
those numbers are just crazy no physiotherapists can keep up to date
with the evident with that amount of evidence or even in the systematic
reviews it’s just those are crazy numbers to expect any clinic
to be on top off so so there are practice guidelines and there’s 48
practice guidelines around the world and there’s also an Australian guideline so
there’s training guideline determines or provides guidance on how we should
measure assess or so assess and treat low back pain so how should we treat low
back pain well this was developed in-into
in the early 2000s and published in 2003 and so it’s very old and in fact it’s
being rescinded in 2013 so ten years later so Australia doesn’t have a
guideline on how to manage acute musculoskeletal pain here but this is
where actually managing acute low back pain guideline was was contained within
that so obviously that’s a bit of a problem because there’s no guard in
Australia to provide any evidence of what you should do to manage patients
that you see with acute low back pain there are guidelines around the world
and we did a review of those a few years ago and actually they all come to face
similar conclusions similar conclusions in fact to the guideline to the
Australian guideline I should actually say that for the last four or five years
we’ve been waiting any day for the garden at straining guard line to be
published I spoke to Michael Nicholas about a year ago and he said they were
almost ready he’s on the panel and we’re still haven’t seen anything okay what
will come on to the development of guidelines as we go through this a
little bit okay so we reviewed them and actually the guidelines are they really
have some common recommendations so and these common recommendations are
consistent so there’s very little around the edges of that this is just what they
suggest and you’re familiar with this right so this is for accurate back pain
you should reassure a patient that their prognosis is favourable advise them to
stay active prescribe medication of necesitan contingent medication
paracetamol anti-inflammatories a second as non non-steroidal anti-inflammatories
muscle relaxants or opioids antidepressants all to anticonvulsant
medication as co medication as a second line discourage bed rest and do not
advise a supervised exercise program well that do not advise a
superfight supervised exercise program wasn’t actually in dias to get the
Australian going line but anyway these are all very similar and this is the
this is the advice to clinicians this is how to manage a patient with acute low
back pain so what happens when patients are managed like that well this is a a
graph I’ve taken this from Nick Henchy initial kept Nick hench G’s publication
in the BMJ in 2008 it’s the results of a study that we did it’s a problem it’s a
cohort study that we conducted in Western Sydney in the mid-2000s we
recruited 275 GPS and physiotherapists and we got them to recruit a consecutive
patients with acute low back pain and then we followed those patients for one
year now we trained the GPS and the physiotherapist to provide guideline
care which is what you’ve just seen so this is what happens to patients when
they’re provided with guideline care you can see I’ll just orientate you to the
graph a little bit so this is the probability of being unrecovered at when
someone within two weeks of developing backpacks the probability of being on
recovered is one that’s what you’d expect
everybody is unrecovered at that point and you can see that in the first couple
of weeks the probability of being recovered drops markedly until it gets
for about three months and then there is a and then there is a considerable
slowdown in the rate of recovery after about three months and and that’s quite
meaningful I think so that there’s a rapid recovery in the first couple of
weeks people tend to recover rapidly but if they get to about three months
there’s a real change in the chitin in the in the rate of recovery I also want
to draw your attention to the proportion of people so this is equivalent the
probability of been unrecovered is equivalent to being to having 40 percent
of people unrecovered from back pain at 3 months and then another year there
about 30 percent so for those still 30% of people unrecovered
in here and that’s a substantial proportion who have been given guideline
care and this is guard line care supposed to be the best available care
so it seems to work for a bit be appropriate for a good portion of people
60% but for the others forty thirty to forty percent really doesn’t seem
appropriate at all so we were interested in whether or not we could improve
outcomes for people who were in receipt of guideline cap so the first trial that
we conducted was in a trial of McKenzie therapy McKenzie therapy for those of
you who don’t know is a standard physiotherapy treatment which is based
on a series of repetitive movement so the patient who were the cure back pain
does a series of repetitive movements and symptoms improved that’s the theory
so we tested whether or not the addition of McKenzie therapy on top of card line
care was was effective added any benefits to patients and it turns out
that of court it doesn’t so these are well it doesn’t really matter which one
is which because you can’t put a pin between them
this is pain intensity decreases for both groups over the first seven days
and up to 21 days so McKenzie therapy this type of exercise therapy has no
effect over gpk doesn’t add anything to guideline care within trialed in a
single trial we had a look at the effectiveness of dr. fernette or spinal
manipulative therapy you know doctor for my case and then say no spinal
management therapy you know what that is as well that’s when physiotherapy
physiotherapists and chiropractors push on try to mobilize vertebra to try and
loosen up stiff vertebrae so that so we there was some suggestion that these may
provide some help on top of on top of from guideline care so we try out those
and again for NSAIDs on top of guideline care no effect again no point looking at
which treatment is which because they’re both exactly the same and same same for
sorry the first one was and said sorry Smt spinal iterative therapy the second
was in sight so no difference between screws okay so where are we well it
looks like we can’t improve on guideline care by adding any exercise on or any
standard type of physiotherapy care like by animal iterative therapy or even
other types of drugs like NSAIDs what about if we take that back of it and
think about what about the effectiveness of from paracetamol well the same story
this is we trialed it sorry this is but by the group I was associated with and I
left or not wasn’t I left being involved on the study so there was a reach our
parish party among two ways regular paracetamol or I’ve so that’s time
contingent or as needed versus placebo and we measure the patient’s 1,650
patients over three months and you can see absolutely no difference so
paracetamol is not effectively there so simple I know it’s usually are not
effective exercise adds nothing and spy removal of therapy has nothing so is
that what it is those forty percent of people cannot who develop chronic back
pain cannot be stopped from developing chronic back pain there’s nothing else
that we can add on to that well let’s just go back to the glass that’s what
the guy don’t say that so yeah that’s what I’ve just been saying so all of
these treatments the treatments are suggesting the guidelines apart from
these other drugs which I’m not going to go into today the rest of those
treatments seems we can’t seem to improve on them but maybe we can think
about this reassuring patients and advice to stay active discouraging bed
rest maybe we can think about that what is the purpose of that about four of
reassuring and potentially dad is something that maybe we can maximize so
potentially patients are getting better and we can maximize help those patients
who aren’t getting better by optimizing the reassures that we give patients
okay well that’s this is the area that I’m really interested in is how to
optimize reassurance for patience and reassurance is what is that that’s a
removal of fears and worries and people come to see you all the time with lots
of fears and worries about that back they’re terrified it’s not going to stop
they’re terrified they’re not going to recover they’re worried that they might
not they may end up in a wheelchair they’re worried that they may have to go
on drugs for the rest of their lives so they have all these fears and maybe if
we can manage those maybe we can help patients to to recover so is that done
in general practice do you as GPS reassure patients do you try to do that
do you provide those interventions reassurance and advice to patients with
acute low back pain and this is a study that paper that we published on the by
having a secondary analysis of data from the beach study now the beach study I’m
sure you’re aware is a study which unfortunately has now lost its funding
but it’s just the most fantastic data area each year yearly a random sample of
GPS were were taken a random sample of a thousand GPS were taken and each were
given a booklet with a hundred sheets in it and on that sheet each GP could write
down for the next 100 concert concert consecutive consultations what was the
reason for consultation and what did you do about it
I mean you can have up to four reasons for a consultation and up to three
reasons that you can things that you did and it’s absolutely fantastic for people
like that for people like me because we can have a really good synaptic provides
a great snapshot of what is hat work GP practices for a condition like for
example low back pain so we have a look at this data and what are the things
what one of the cut one of the treatments that a patient can get is
advisor educational counseling and only an 80 percent of GP said that they did
not provide that to the patient now that doesn’t mean you didn’t talk to the
patient but the GP still provide something to the patient which they
considered was an education or specific advice which I think is quite amazing
because probably you think you do that all the time but it’s not maybe thought
of as an intervention so therefore it’s not optimized in some follow up work by
my colleagues Chris Williams he did some qualitative work with GPS to find out
what was the reason for what do they think about guidelines and how did they
think about implementing guidelines so that have any meaning for their lives as
clinicians and they said that the the things that emerged was that guideline
recommendations didn’t really constitute satisfactory care for them they thought
it was challenging and beyond the scope of a 20-minute consultation to do it
really properly to provide proper advice and education and they probably required
some support in order to engage patients and this type of behavior this type of
intervention so with that we thought okay well how if we wanted to really
improve this how would you do this so what does the literature say on advice
and education and reassurance what does it say how would you reassure a patient
well before I talk about this particular systematic review I just wonder whether
or not you anyone has used a diagnostic test to reassure their patient like
exact diagnostic tests like the results of a scan for example or a blood test
even if for someone who has acute low back pain not using it to to determine
whether the patient has a particular condition but using it in order to
reassure a patient well there is quite good research now to say that actually
that’s a very bad approach to reassure a patient in fact that patients who
receive tests in fact worried patients who receive tests actually become more
worried when the reasons for that we think is because it’s because even
though they initially feel quite they feel quite happy as soon as they go
out of your office they think maybe something’s being missed if they’re
highly anxious they think something’s being missed or something unusual is
happening they’re still not recovering but they didn’t find anything on the
tests or what’s going on things are just really and it doesn’t help them their
their emotional distress in fact it might make them worse so but one type of
intervention might be successful and that’s patient education so we wanted to
know does patient education reassure patients with acute low back pain we
conducted this systematic review and what we found was and you can see here I
just orientate you very quickly so these are the studies here and these are the
effect sizes produced by the studies and their confidence intervals and that’s
the pulled effect this you know this is the pulled effect so in the short term
pain a patient education did improve did reassure patients and in the long term
it reassured patients so simple patient education was able to reassure patients
it also it was delivered you like this it was delivered it was delivered by GP
I had a stronger effect it’s delivered by a physiotherapist or nurse actually
had no thing so really if you a GP deliver a patient should get patient
education two occasions they believe you and they feel reassured it’s good news
the nice thing about this as well leads to reduce Hospital consultations future
at hospital consultations twelve months after the visit so people are reassured
and that’s a nice evidence of them being reissued okay so now I take a stop there
because I’m going to say that up until now where are we okay so we have some
guidelines that were produced around the world in the early 90s into the 2000s
early 2000s and then they all came to a similar conclusion we should treat
patients all in the same way so a patient comes in they should all just be
giving guideline advice they should be given gun advice and reassurance nothing
else improves on that so okay that’s it just recently there has been some
guidelines which has suggested an alternate approach and I just want to
offer you a little bit about the alternate approach now so the alternate
approach is was proposed really by the nice guideline which is the UK guideline
this is the publication of it here in the BMJ last year since then the the
belgian guideline has also said very similar things echoed very similar
thoughts to the mice guideline but others like the American College of
Physicians have not and they’ve said no continue to treat people
one-size-fits-all so treat all patients in the same way now the difference about
the nice guideline is that the nice guideline is suggesting that we treat
patients according to their prognosis rather than according to any assumed
diagnostic any diagnosis that they have so treat them according to their
prognosis so for patients for example here it is here it’s bit complicated but
I’ll just show you very quickly so if a patient comes in with back pain they
they should be they can well they say consider but really they’re starting to
say that we should use a screening tool or prognostic screening to light their
start battle that’s produced by keel University in the UK and for patients
who score well on that so they have a good prognosis
they really just get advice on on self-management for patients who have a
moderate or poor outcome there are other options to think about my own therapy
which we know doesn’t work some group exercise again we know doesn’t work
some combined physical and psychological problem and psychological therapies well
some of these might might work a little bit we don’t we don’t know about that
they’re based this advice on a trial that they did that was published The
Lancet a few years ago which showed that though that patients who received care
in this style so this was if this is stratified care they’ve called it do
better a little bit well let’s say do better a little bit they
most people to this type of intervention so stratified care versus just everybody
treated the same and there was no differences on pain intensity that there
was difference on just brought the disability and it was a small difference
but it was cost-effective so this has now gone into the this is now being
pushed through different guidelines and let’s see what happens at the Australian
guideline but I wouldn’t be at all surprised if it has something like this
okay and so the first thing so what’s up so as a group we were really interested
in this approach because it suggests that it gives clinicians something a
little bit more meat than just treating everybody in the same way which we know
doesn’t work so maybe if we can identify people who are at a high risk of a poor
outcome and we target them with additional therapies can we prevent them
from becoming chronic the people who are at a low risk of developing chronicity
go off developing chronic pain maybe if we just treat them with standard
guideline care that’s enough okay trick is how do you identify people with acute
lower back pain who are a high risk of a full recovery there are some ones I
mentioned at the start back tool and we were interested in what other two if
there are any other tools available and the two really that we came up with
really when did a systematic review the best two were the start back tool and
the where everyone just shorts it shortens us to the arre bro so this is
the Arriba you might have heard of it as a yellow flags start back is quite new
it’s been tested on quite a lot of people doesn’t do brilliantly though and
I mean this is the this is the pooled area under the care of the area under
the curve is a is a it is a surrogate measure of accuracy you can think about
0 is I will actually 4.5 is chance and 1 is perfect so it’s a bit of a bet
another chance same for the Arriba okay so the tools
don’t do fantastically for people with acute low back pain so we decided to try
and develop our own and I just talked you through that very very quickly now
so this is our own study we developed on a large sample of firm 1200 patients
and this is their characteristics here and we tested it validated on another
large sample of 1,600 patients this is their characteristics and you can see
that there are slight differences that’s nice you really want your validation
sample to be different from your development standpoint and what did we
find right well so I’m going to compare it to
start back to because that’s what’s being suggested by the nice guidelines
these are the five studies that have provided a effect size plus their
confidence intervals testing how well the start back predicts people who to a
high risk of a poor outcome how well the start back predicts people people’s
outcome this here is the is the pulled effects that’s a way to pull the fact
that’s a start that’s a start back to the pickup still doesn’t it better
actually so we’re pretty happy about that and I just want to put this in here
as well just so that you’re aware actually it both of them do vary too
much better than clinical judgment we took this from Mark Hancock study a few
years ago with Mark asked Paige asked GPS to and physiotherapist to predict
whether that patient who was in front of them would develop chronic pain and both
these tools do much better so it’s probably very useful to use these tools
I would say so what does our tool which is the winner of course we don’t know
otherwise why I’m presenting it to you today
what is our to look like ok so right so this is it and we in fact have not just
taken we’ve taken the tool that we developed and we’ve turned into not just
a prediction tool we’ve turned it into what we think what I like to think is a
clinical tool I think it’s something which is helpful for you and for your
patients so this is what it looks like it’s five very simple questions right
the first question how much back pain have you had you in the previous week
the next one do you have a leg pain is your back pain compensable how much
you’ve been fathered bothered by fees up to by feeling depressed in the last week
and in your view how large is the risk that your current pain
become persistent and these are the response categories you can see here
some patients can just fill those in this is online and they can fill those
in and that patient with that kind of response that response pattern would
have a predictive probability of 40% there were 40% predictive probability of
developing chronic pain and we think that’s useful information for you as a
clinician to have and probably useful information for a patient to have
because if you do nothing and you continue just with guideline care this
is the probability that you will develop chronic pain now let’s decide what we
should do about that can we target interventions to reduce that probability
to reduce your risk of developing chronic pain just quickly this is the
result so the patient gets this is actually the results not for that one I
just showed you but for someone who had a very good prognosis so you’re a very
low risk it means you’ve got a good chance of a full and rapid recovery
green light to stay active gradually reduce drug reduce your turn you return
to user activities you can get some other help if you like and you might
feel it right now but backs are very strong we want to get some very positive
messages here anyway you can see how that goes okay this is online and it’s
available for use okay so with our tool we now think we can identify patients
who are at a high risk of a media are moderate and high risk of a poor
recovery what do we do with those patients well as I was saying before
that it looks like for most patients we can reassure we can optimize reassurance
by educating patients well is there a type of education that we can provide
for patients an optimize type that might be even better at reassuring patients
who are a high risk of a poor outcome so this is the trial so we we were
interested in patients with acute low back pain and this is the inclusion
criteria and exclusion criteria it’s what you’d usually see and we use the
pick up calculator this is someone it’s obviously a very high risk of a poor
outcome and what about the intervention well
the intervention was based on the explained paying program developed by
Norma Mosley and David Butler and they produced this book in 2002 I think and
it was updated last year cause explain pain supercharged it’s very interesting
book and basically it’s developed from the work of Patrick wall and basically
yeah it’s an attempt I believe to reassure patients by explain to them the
biology of their pain for to let them understand to make them understand why
they’re in pain and why it might be a good thing for them to get moving again
so very quickly this is the very broad principles you hurt yourself or youth
you there’s a threat to some tissue those signals are sent up into your
brain your brain processes those signals and ask the question how dangerous is
what’s happened at the periphery and if there is a this there is a processing
which suggests brain process of that to suggest that there is a threat a real
threat then you will experience pain and that’s a diagram taken from his book
that’s supposed to be paying the orchestra playing pain so that’s very
simple so the brains role is how dangerous is
to assess how dangerous is the sensory information that I’m getting from my
from my body how dangerous is it really and lots of things feed into that lots
of beliefs though the situation memories context they all feed into that for
example we know that people who say I live I will have pain for the rest of my
life tend to do a bit worse there’s something seriously wrong my back so
there’s those people who are really fixed on a BIOS like on a biological
biomed approach tend to do badly so why do they
tend to do badly well this is the this is the approach that Moseley and Butler
take and I think it’s worthwhile just going into this just a little bit
because I think it’s quite interesting and something you might be able to
explain to your patients this is called the Twin Peaks and this just means that
if you have back pain sorry if you’re a person and you are climbing up this
mountain this peak here you get to a point we’re getting very very tired you
and there’s a threat to your tissue that you might damage your tissue and that’s
where the threat is it’s right near the top of the mountain so if you go any
further you will damage your tissue what your brain does is it puts a barrier
just before that and that barrier is when you start to feel pain so you plan
up the hill and you get to this point and you start and you get back pain and
what your brain is saying is take things a bit easier because you’re approaching
tissue damage here you’re damaged your tissues might get damaged okay so what
happens if you do develop back pain and you do damage a little bit of tissue
some tissue then your brain real OERs the the the threshold for tissue injury
because there are some vulnerabilities in the tissue but what but what the
brain does it becomes very protective of the tip of that tissue so it puts the
lowers the threshold for experiencing something to protect yourself which is
pay back pain lowers the threat and puts this big buffering so this buffer stops
you from really seriously injuring the tissue and that’s when you experience
pain I think this is quite a helpful model for patients I think we have
childís and the patients seem to really like seem to understand it so yeah
that’s the safety buffer so what do you do with that safety butter butter buffer
well over time for example if you took this for a six weeks prior six weeks
program of just getting back to your usual activities you can increase the
buffer so if you do a bit of exercise you can increase
don’t decrease the buffer over time as you can see there until eventually the
buffer goes back to its normal position which is nearer tissue damage and then
you reduce your back pain so you can do more things without experiencing back
pain and as I said before what happens in here is there are all those beliefs
and thoughts and memories about the situation that you’re in all of those
contribute to the size of this buffer because you can make it very big if
you’re very fearful and make it small if you’re not so fearful so that’s really
what happens over time so we use that think it’s very very interesting and we
decided okay well we’re gonna that takes two hours to explain this over two
sessions and we thought where these people are going to do very badly high
risk of doing very badly what happens if we intervene and we treat them with this
with this intervention this reassurance intervention optimized reassurance we
controlled the control group with sham education so those patients were being
educated and the control group with sham education and that was just our
physiotherapist you can see him here this is a PhD student Adrian and he’s
just talking to the patients talking to a patient about letting the patient talk
actually is what they’re doing so not giving any advice or any education just
being there with the patient and this controls for time and for the provision
of information okay these are the primary app.this of the outcomes primary
outcomes pain intensity on those standard student 10 NRS and lots of just
lots of secondary outcomes we recruited we randomized 202 and we had a 95
percent follow-up at 3 months and in fact over one year was my just was 93
percent so you were very happy with that takes a lot of effort but we were very
happy so what are the results ok pay attention well actually that’s the
that’s a sham group did the pet did the active group do any better
well no fortunately they didn’t do any better what about disability because
that’s the other important yeah that’s the Shan Group did the did
the intervention group do any better yep they did do better in the short term so
we were able to reduce people’s disability in the short term so get them
better a bit quicker and then people in the sham group caught up so you can so
they’re so by reassuring people with his intervention you can get reduced their
disability but not their pain intensity what about the secondary outcomes okay
so no effect was Sham for the further for those secondary outcomes but some
other interesting effects for example recurrence people had in the
intervention group had reduced rate of recurrence quite markedly reduce
actually that’s about twice 2 times 2 times less likely to have a recurrence
and they also reduced their pains and sorry we also were able to reduce change
that their attitudes what they thought and also were able to reassure them as
well so that’s the results of that trial and just to go just to conclude from
that so patient education did not influence pain intensity of 3 months
compared to sham but it might have other effects we can reduce short-term
disability and recurrence and reduce healthcare use and increase reassurance
so we think this is pretty interesting and I think this is the sort of starters
to try to think about what do you do with that group it’s buying to be able
to identify a group or a high-risk it for poor prognosis but what do you do
with them and this is one potentially promising thing and we can play around
with actually what we did in the intervention one potentially of
potentially promising intervention but what else do we do unfortunately just
don’t have the answer for that yet so just to summarize okay so that’s um the
end of the talk I don’t think that I’ve brought any closer to that question what
are they done for us one of the apps of God have they improved
the guidelines improved our lives but what we do know is that a substantial
minority of people with acute low back pain who receiving diet standard
guideline care will develop chronic back pain and the guideline care cannot
doesn’t seem to be able to be improved on with any of the standard approaches
that we have what I think that won’t be nice if you would consider is to using a
prognostic screening tool to identify patients that are high risk of a poor
outcome and discuss their prognosis with the patient so use this as a tool to
open discussion about what the paper what kinds of interventions a patient
would like to do i’ve got obviously said my back there that’s a tool that we’ve
got but of course use other and there are other tools available as well and
what we also know is that really good quality education so taking time to
educate a patient about their bang reduces their disability and which is
the rate of recurrence and their future he’ll say how seeking behavior so we
think those are really positive outcomes now we’re not there yet obviously in
trying to prevent everybody from developing chronic back pain but we
think that this is a really nice way to start and so thank you very much to take
any questions

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