Optimising first-line care for low back pain and new directions

Low back pain is common and burdensome. The economic burden of low back pain in Australia includes total costs that exceed A$8 billion per year, costs which are projected to increase by 60% over the next 10 years. Less is known about the personal burden of low back pain. The first-line treatment consistently recommended for people with low back pain is patient education and advice. Regardless of the duration of low back pain, clinicians should provide advice to remain active, education on the benign nature of low back pain, and reassurance about the absence of a serious medical condition. Little guidance is available on how best this can be achieved. New treatments are urgently required to stem the rising costs of low back pain. Two proposed strategies are repurposing medicines, such as sleep medicines and media campaigns to target unhelp behaviours and beliefs. The overarching aim of this thesis was to investigate the personal burden of low back pain, evaluate attitudes toward education and advice for low back pain and explore contemporary options for managing low back pain. The methods used included qualitative content analysis, an observational study, development and evaluation of a new measurement tool, a systematic review and a randomised controlled trial. People with and without low back pain, online and in-person were recruited to participate across the five studies. The findings from each study are presented in individual chapters. The evidence in this thesis provides a scientific basis for understanding the personal burden of low back pain. The results describe how evaluating attitude toward education and advice could enable clinicians to tailor the patient education and advice they provide. Specific messages of reassurance rather than information about staying active should be prioritised. The Attitude toward Education and advice for Low back pain Questionnaire (AxEL-Q) is a valid and reliable tool to provide clinicians with an insight into attitudes toward education and advice at the outset of a clinical encounter. Sleep medicines should be further investigated before being endorsed to reduce pain intensity in people with acute low back pain. Social media and digital health interventions such as conversational agents provide options for supplementing low back pain management in the future

Sleep and pain: relationship and management

AbstractBackgroundResearch has identified that sleep and pain have a bidirectional relationship. Understanding this relationship specifically between chronic low back pain (LBP) and sleep may lead to improved management of painful conditions such as chronic LBP and postoperative pain. As pain is typically more difficult to manage the longer it persists; an advantageous approach to management of chronic pain may be to intervene early to prevent the transition from an acute episode to a chronic problem. Targeting sleep during an acute episode of pain may provide an option to accelerate recovery and prevent chronicity. MethodsThis project included 3 studies. The first study used a cross-sectional design to investigate the bi-directional relationship between chronic LBP pain and sleep. Correlations were used to determine whether pain intensity during the day was associated with differences in sleep architecture and whether these differences were associated with pain intensity the following day. The second study used a systematic review with meta-analysis to investigate whether managing sleep in the acute postoperative period improved postoperative pain.The third study was a pilot randomised controlled trial that investigated the feasibility of managing sleep in participants with acute low back pain. ResultsThis research found that: 1.For people with LBP, slow wave sleep (SWS) and sleep quality were significantly associated with next day pain intensity such that people with LBP who spent less time in SWS reported both higher pain intensity the following day and worse sleep quality for the same night. 2. Hypnotic drugs in combination with other analgesics significantly improve pain and sleep post-operatively, however the effects were modest. 3. The pilot study identified barriers to recruitment necessary to address in a large trial in order to ensure completion in a practical timeframe, in a sample of Australian primary care practitioners. Those enrolled found the questionnaires suitable and the follow-up rates were good. ConclusionsThis research is a useful platform to better understand the complex relationship between pain and sleep. It provides a guide for future research in the area. Enhancing sleep quality continues to be a potentially undervalued resource in improving LBP and postoperative pain

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A survey to investigate the attitude of the general public toward recommendations for the contemporary management of low back pain

Effect of graded sensorimotor retraining on pain intensity in patients with chronic low back pain : a randomized clinical trial

Importance: The effects of altered neural processing, defined as altering neural networks responsible for perceptions of pain and function, on chronic pain remains unclear. Objective:To estimate the effect of a graded sensorimotor retraining intervention (RESOLVE) on pain intensity in people with chronic low back pain. Design, setting and participants: This parallel, 2-group, randomized clinical trial recruited participants with chronic (>3 months) nonspecific low back pain from primary care and community settings. A total of 276 adults were randomized (in a 1:1 ratio) to the intervention or sham procedure and attention control groups delivered by clinicians at a medical research institute in Sydney, Australia. The first participant was randomized on December 10, 2015, and the last was randomized on July 25, 2019. Follow-up was completed on February 3, 2020. Interventions: Participants randomized to the intervention group (n = 138) were asked to participate in 12 weekly clinical sessions and home training designed to educate them about and assist them with movement and physical activity while experiencing lower back pain. Participants randomized to the control group (n = 138) were asked to participate in 12 weekly clinical sessions and home training that required similar time as the intervention but did not focus on education, movement, and physical activity. The control group included sham laser and shortwave diathermy applied to the back and sham noninvasive brain stimulation. Main outcomes and measures: The primary outcome was pain intensity at 18 weeks, measured on an 11-point numerical rating scale (range, 0 [no pain] to 10 [worst pain imaginable]) for which the between-group minimum clinically important difference is 1.0 point. Results: Among 276 randomized patients (mean [SD] age, 46 [14.3] years; 138 [50%] women), 261 (95%) completed follow-up at 18 weeks. The mean pain intensity was 5.6 at baseline and 3.1 at 18 weeks in the intervention group and 5.8 at baseline and 4.0 at 18 weeks in the control group, with an estimated between-group mean difference at 18 weeks of −1.0 point ([95% CI, −1.5 to −0.4]; P = .001), favoring the intervention group. Conclusions and relevance: In this randomized clinical trial conducted at a single center among patients with chronic low back pain, graded sensorimotor retraining, compared with a sham procedure and attention control, significantly improved pain intensity at 18 weeks. The improvements in pain intensity were small, and further research is needed to understand the generalizability of the findings