Neck and back Pain: What’s Best Practice?

Low back pain is the primary cause of disability burden in Australia (Global Burden of Disease, 2015) resulting in an annual cost of $4.8 billion to the Australian healthcare system (Arthritis and Osteoporosis Victoria 2013).

The 2018 Lancet series on low back pain (Buchbinder et al 2018, Foster et al 2018, Hartvigsen et al 2018) suggested that the societal impact of low back pain is largely due to excessive use of ineffective treatments.

This includes unnecessary imaging, over-prescription of pain medications (like opioids) and spinal surgeries, and an overemphasis on passive therapies primarily aimed at symptom relief.

Our understanding of optimal care for low back pain has evolved in recent decades (Lin et al 2020). Inappropriate utilisation of certain pain medications, prolonged bed rest, and surgical interventions are now recognised as having limited utility in most cases of low back pain (Lin et al 2020, Maher et al 2017, Chiarotto et al 2022).

Imaging should be reserved for cases where serious pathology or fractures are suspected, as routine imaging does not typically improve patient outcomes (Maher et al 2017). For the majority of cases (about 95% of presentations in certain care settings) where serious pathology is not suspected, identifying and addressing both physical and psychosocial barriers to recovery is fundamental to initial care (Lin et al 2020, Traeger et al 2021).

A clinical diagnosis of for spinal pain is not strictly reliant on radiology, and therefore, a robust physical examination is often sufficient to exclude worrisome pathology and identify likely contributing structural sources of pain. A comprehensive understanding of other non-structural contributors to pain such as poor sleep, reduced physical activity, general health and stress can also provide explanation as to why someone might be experiencing pain.

Effective care should be centred around the patient, with clinicians responding to individual circumstances, employing clear communication, and engaging in shared decision-making to determine the best course of action forward and aligning this to the patient’s preferences (Lin et al 2020). This involves providing personalised reassurance and validation to patients, along with education aimed at fostering a positive outlook regarding their condition, and guidance promoting self-management. Central to this approach is empowering patients to regain confidence in engaging with movement, physical activities, social interactions, and work (Lin et al 2020).

For patients who do not respond adequately to initial care, or who are identified through risk assessment as unlikely to respond, targeted physical and psychological therapies addressing barriers to recovery are recommended (Chiarotto et al 2022).

In short, a graded exercise therapy program can help patients gradually reintegrate normal movements and activities aligned with their personal goals. Limited-duration manual therapy may offer pain relief, but this needs to be complementary to an active management strategy (Lin et al 2020). In cases where psychosocial factors significantly impact patient presentation, referral to psychological services can be beneficial to addressing pain-promoting behaviours and thought patterns.

References:

1.     Australian Burden of Disease Study: impact and causes of illness and death in Australia (2015)

2.     Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, Croft P; Lancet Low Back Pain Series Working Group. Low back pain: a call for action. Lancet. 2018 Jun 9;391(10137):2384-2388. doi: 10.1016/S0140-6736(18)30488-4. Epub 2018 Mar 21. PMID: 29573871.

3.     Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG; Lancet Low Back Pain Series Working Group. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018 Jun 9;391(10137):2368-2383. doi: 10.1016/S0140-6736(18)30489-6. Epub 2018 Mar 21. PMID: 29573872.

4.     Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M; Lancet Low Back Pain Series Working Group. What low back pain is and why we need to pay attention. Lancet. 2018 Jun 9;391(10137):2356-2367. doi: 10.1016/S0140-6736(18)30480-X. Epub 2018 Mar 21. PMID: 29573870.

5.     Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, Straker L, Maher CG, O'Sullivan PPB. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020 Jan;54(2):79-86. doi: 10.1136/bjsports-2018-099878. Epub 2019 Mar 2. PMID: 30826805.

6.     Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017 Feb 18;389(10070):736-747. doi: 10.1016/S0140-6736(16)30970-9. Epub 2016 Oct 11. PMID: 27745712.

7.     Chiarotto A, Koes BW. Nonspecific Low Back Pain. N Engl J Med. 2022 May 5;386(18):1732-1740. doi: 10.1056/NEJMcp2032396. PMID: 35507483.

What is Osteoarthritis?

Osteoarthritis (OA) is a condition that affects the whole joint including bone, cartilage, ligaments and muscles. Although often described as ‘wear and tear’, OA is now thought to be the result of a joint working extra hard to repair itself. OA may include inflammatory changes of the tissue around a joint, damage to joint cartilage, bony spurs growing around the edge of a joint and/or deterioration of ligaments (Arthritis Australia, 2017).

OA can affect any joint but occurs most often in the knees, hips, finger joints and big toe, and it can develop at any age but tends to be more common in people aged over 40 years or those who have had previous damage to the joint or joint injuries. 1 in 5 Australians (22%) over the age of 45 have osteoarthritis (Arthritis Australia, 2017).

Certain factors can often predispose a person to having an increased risk of developing OA, including, but not limited to previous job history, being overweight, family history of OA or previous injuries.

When it comes to discussing OA, it is important to distinguish between what is called ‘radiographic’ versus ‘clinical’ OA. Put simply, radiographic OA refers to changes on imaging (such as an x-ray) which show the physical changes occurring within the joint. Having said that, some people may have evidence of OA on radiology, but not have any discomfort or pain associated with these changes.

Conversely, others may have radiographic changes of OA and also experience pain associated with these physical changes in addition to other risk factors which may sensitise them to experiencing pain.  

The poor relationship between features of osteoarthritis on imaging and symptoms has been well documented, meaning that the reason you may be experiencing pain in your joints is not strictly related to osteoarthritis. It is important to understand how osteoarthritis affects the individual’s function (including physical activity), quality of life, relationships (personal and professional), sleep, medication use and any other relevant medical conditions (RACGP, 2018) as these features can impact the pain experience outside of the physical changes to the joint itself.

Surgery is certainly not a first line recommendation to manage or ‘fix’ OA. Unlike hip replacements, knee replacement outcomes are not quite as good and recovery is definitely longer (Blom, 2016). Aside from the risks associated with surgery, the literature reports a 1 in 5 dissatisfaction rate in knee replacements (Gunaratne, 2017). Mild arthritic changes should not have joint replacement surgery (Arthritis Australia, 2024).

Exercise and weight loss are the recommended first line treatment strategies to managing osteoarthritis as this helps to reduce mechanical stress on the joint and manage the systemic inflammatory changes associated with inactivity and excess weight (Wang et al 2015).

Having a diagnosis of OA is not a sentence to living with lifelong pain – receive the right guidance for you to help get yourself back on track to living well with osteoarthritis.   

References:

What is Osteoarthritis? Arthritis Australia. (2017) https://arthritisaustralia.com.au/types-of-arthritis/osteoarthritis/

Guideline for the management of knee and hip osteoarthritis. RACGP (2018). https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/knee-and-hip-osteoarthritis

Gunaratne R, Pratt DN, Banda J, Fick DP, Khan RJK, Robertson BW. Patient Dissatisfaction Following Total Knee Arthroplasty: A Systematic Review of the Literature. J Arthroplasty. 2017 Dec;32(12):3854-3860. doi: 10.1016/j.arth.2017.07.021. Epub 2017 Jul 21. PMID: 28844632.

Blom AW, Artz N, Beswick AD, et al. Improving patients’ experience and outcome of total joint replacement: the RESTORE programme. Southampton (UK): NIHR Journals Library; 2016 Aug. (Programme Grants for Applied Research, No. 4.12.) Chapter 2, General systematic review methods: systematic reviews of long-term pain after hip and knee replacement, methods used to assess chronic pain and pre-operative predictors of long-term patient outcomes.

Physiotherapy In Motion. Five facts about osteoarthritis (2022). The Australian Physiotherapy Association. https://australian.physio/inmotion/five-facts-about-osteoarthritis

Image cited from the Physiotherapy in Motion (APA) (2022).

Advanced Practice Physiotherapy

Within the medical field, it is well understood that medical professionals operate within a wide range of disciplines (e.g., neurology, orthopaedics, rheumatology etc). Furthermore, a clinician’s educational and experiential background will dictate their seniority and expertise within their area (e.g., junior orthopaedic registrar versus senior orthopaedic consultant). Subspecialties also exist within each discipline (e.g., orthopaedic knee surgeon versus orthopaedic foot/ankle surgeon) to provide patients with more specialised care.

Similarly, within the world of allied health, not all physiotherapists are credentialed equally. Physiotherapists work across a variety of fields - musculoskeletal, neurology and cardiorespiratory to name a few. Physiotherapists have the opportunity to pursue further training beyond their base level qualification to allow them to become more skilled within their selected area and extend their scope of practice.

One such area of extended practice scope exists within a subset of physiotherapy called Advanced Practice Physiotherapy (APP).

Advanced practice physiotherapy roles have been established in Australia for nearly two decades, primarily focusing on musculoskeletal care within public health settings. These roles leverage extensive clinical expertise to assess and autonomously manage a specific group of patients, often presenting with complex conditions.

In emergency departments throughout Australia, advanced musculoskeletal physiotherapists independently handle cases like simple fractures, dislocations, spinal pain, and soft tissue injuries. They collaborate closely with medical specialists and surgeons, evaluating patients on public health waiting lists in fields such as neurosurgery, orthopaedics, and rheumatology.

Distinguished by their high-level decision-making and risk management responsibilities, advanced practice physiotherapists operate in distinctive healthcare settings, setting them apart from standard physiotherapy practice. Due to completion of extensive and rigorous training programs under Medical Consultant mentorship, these professionals demonstrate strong diagnostic alignment with specialists such as orthopaedic surgeons.

As an APP and Titled Musculoskeletal Physiotherapist, Sharlene is skilled in delivering high quality, evidence based care and accurate diagnosis to her patients. She specialises in providing second opinion management for complex pain conditions.

The above infographic has been cited from the Australian Physiotherapy Association - full reference details can be found below:

Reference: Advanced Practice Physiotherapy. The Australian Physiotherapy Association: Physiotherapy in Motion. W. Milway, R. Charteris, P. Truter, M. Cruickshank, C. Farmer (2022).