Back pain: A new way of doing things

The biopsychosocial model of pain, where pain is affected not just by ‘physical’ factors, but also a range of other ‘non-physical’ factors – is not new – but despite being around for decades, we have really struggled to implement this into clinical practice. It is all very well saying body and mind are connected in theory, but how do I actually address that in a person with back pain who comes in thinking they have damaged a disc in their back and who insists that they need an MRI scan? In this approach, we spend a lot of time listening to their story, trying to compassionately connect the dots between their back pain and the various triggers for pain in their life. 

Similarly, while it makes sense that people are different, and might need slightly different care, it is hard to sometimes see how this can be done in a coherent, evidence-based way. There is a risk that ‘personalised’ care becomes too vague and ‘anything goes’.

Cognitive functional therapy (CFT)

In CFT, all components of treatment are based on clinical guidelines, but they are targeted to the needs of the person. For some, there may be a large focus on making them more active, as they are worried they might damage themselves, or are concerned about something that has been reported on an MRI scan – for others, the focus may be more on their sleep, stress or general health. 

This approach to personalised, biopsychosocial care has now been tested in four clinical trials – three of which have involved an intensive training programme, using relatively experienced clinicians, with a major level of oversight, competence assessment and fidelity monitoring. The fourth – in Brazil – used a single newly qualified physiotherapist to try to implement this approach. All trials – except the Brazilian study – showed encouraging results for pain and disability, despite using different clinicians, in different countries, and compared to different control groups. 

The latest trial is the biggest, and arguably best, thus far. It had the most patients (almost 500) and clinicians treating (18). It maintained the benefits for longer than previous trials, likely because they included ‘booster’ sessions after six months, where patients were brought back in one more time to check their progress, and problem-solve any issues. 

Critically, it is only the most recent Lancet trial which undertook a full economic analysis as to whether the time/effort involved in upskilling physiotherapists was worth it – and the results are very conclusive. Both groups that received CFT ended up costing society over Aus $5,000 less (just over €3,000) per patient in the first year after being treated – most of the saving resulting from getting people back to work earlier and more often.

Some might argue the training (almost 100 hours) is too much to implement – but becoming an expert in anything (eg, surgery, clinical psychology, dentistry) does not happen overnight, and we are starting from a position of weakness, where many long-qualified clinicians have outdated beliefs.

Some implications 

• We need to change how we treat clinicians who treat back pain – not just physios, but doctors, chiropractors, etc.

• We need to upskill those who are already qualified, as this is quite different from how people were trained (including myself).

• We need to spend less money on tests and treatments that are unhelpful and often expensive (eg, MRI).

• We need to spend more money providing support for self-management across not just back pain, but a range of long-term conditions. Critically, this does not have to look like traditional ‘treatment’ in a hospital, but could be compatible with health promotion/disease prevention approaches as outlined in Sláintecare.

• Some might view this as a justification for multidisciplinary team approaches to persistent pain. These programmes might have a role, but their cost and the associated resource challenges mean their cost-effectiveness has been questioned. Instead, the reality is that back pain will continue to be mostly treated in primary care or private practice, often by a single clinician. Therefore, we need to train these clinicians to think more broadly, and also improve their ability to refer on, or signpost patients, appropriately. 

• At a societal level, members of the public still think back pain is a sign of significant damage to the body, and until that changes, we are not likely to see a major reduction in the number of people seeking scans of their back. In a similar vein, we need to change all the messaging, which reflects the vulnerability of the spine, eg, manual handling training consistently makes people more paranoid about damaging their backs, and every September we see warnings that fit, healthy active children can be easily damaged by carrying schoolbags, despite all the evidence rejecting that idea.

Prof Kieran O’Sullivan, Associate Professor in Physiotherapy, Course Director MSc in Physiotherapy, School of Allied Health, University of Limerick