Thread by @KWernliPhysio

1/25
LBP Best practice and Current Evidence

Twitter thread summarising Professor Nadine Foster's presentation from the Nordic Back Pain Seminar/Webinar highlighting the @TheLancet #LowBackPain series paper 2: @pain_eddotcom @KeelePain @KeeleUniversity @CurtinUni

2/25
Overlaps with Prof @RachelleBuchbin der's presentation.
Much of modern back pain care is ineffective and/or harmful.

3/25
Weak evidence base for PREVENTION of LBP
✅Exercise and Education (together), Exercise (alone) shown effective in Adults
❌Education (alone), back belts, shoe insoles, ergonomic intervention NOT EFFECTIVE
✔️very low quality evidence for ergonomic school furniture in kids

4/25
BEST PRACTICE EDUCATION AND SELF-CARE INTERVENTIONS:
✅Advice to stay active (and at work)
✅Education (reassure, contextualise, contemporary based on guidelines)

5/25
BEST PRACTICE: Non-Pharma
Routinely use as first line treatment:
✅Exercise therapy and Cognitive Behavioural therapy (#CBT)
❓Everything else on this picture second-line treatment or there is insufficient evidence

6/25
BEST PRACTICE: Pharmacological Therapy
🙅‍♀️No green (recommended as 1st line) on this slide
❌Paracetamol
❓NSAIDs, muscle relaxants, antidepressants.
⚠️Opiods

7/25
BEST PRACTICE: INVASIVE TREATMENTS
🙅‍♀️Also no green on this slide (nothing routinely recommended)
Upside?: we are seeing better collaboration between clinicians, researchers, funders to research this (e.g RFN trial in Netherlands)

8/25
KEY MESSAGES FOR BEST PRACTICE
🗓Over time, all guidelines:
• place much less emphasis on Pharma and invasive treatments (surgery)
• advise against electro physical modalities (eg ultrasound)
• Discourage routine imaging

9/25
Unfortunately, poor value healthcare is already well-entrenched in LMIC countries.

"THEY ARE ALREADY FOLLOWING OUR FAILURES"

10/25
LESSONS
• KEY error was seeing LBP through solely a medical lens
• Fusing the spine to stop 'abnormal movement' is an error in surgical management. ('abnormal movement' does not appear to be the cause of LBP)

11/25
NEW DIRECTIONS: Public health
• Guidelines recommend LBP is best managed with MINIMAL medical intervention, advice to stay active and at work, but this is the OPPOSITE to what the public believe.
• eg. Indigenous Aussies beliefs went biomedical only following HCP encountr

12/25
NEW DIRECTIONS: Public health and Mass media:

Key messages are SPOT ON, why isn't this stuff still being pushed @GregHuntMP? it was proven effective as you'll see in next tweet. @DrChrisBarton

13/25
NEW DIRECTIONS: Public health and Mass Media:
✅Effective at changing beliefs
❌Mostly ineffective at improving outcome (unless you spend lots of 💰 like AUS did 🇦🇺
"WE MUST HARNESS PERSONALISED MARKETING" (the same way you get personalised adds for online shopping)

14/25
NEW DIRECTIONS: Public Health
Nadine Foster appealed to LMIC to replicate the AUS campaign but utilising contemporary media (social media, personalised marketing)
🔍FOCUS on changing BEHAVIOUR (care-seeking behaviour), not just beliefs.

15/25
NEW DIRECTIONS: Social & Work
• HUGE differences in LBP claims dependent on geographical location)
• We need to change from passive benefit systems to employment promoting systems

16/25
New directions: Social & work
An example of positive change from The Netherlands, a country that deliberately changed to a model of more work and employment promoting interventions.
(more on next slide)

17/25
The Netherlands forced employers to pay 70-100% of the worker with pains wages for TWO YEARS, and postponed medical assessment for work disability to 2 years... the result:less sick leave.
(emerging evidence only as no control group)

18/25
NEW DIRECTIONS: Healthcare
⁉️The evidence to practice gap is PERVASIVE (~17 years)
• huge opportunity to help just by implementing what is already known
• Guidelines are not enough, implementation needs repetition and needs to be ongoing.

19/25
KEY ISSUES in slide:

"In many countries we have a BIZARRE situation where we reimburse based on how MUCH care a patient gets, rather than the QUALITY of that care" - this needs to change

20/25
Changing the clinical care model

💡Managing patients based on prognosis, NOT diagnosis

21/25
We need to be efficient.

Good example is work by @DrJonathanHill and others at @KeelePain @KeeleUniversity - STarT Back stratified care model which changed healthcare practice and improved cost-effectiveness.

22/25
Changing clinical Pathways:
✅Make HCPs with training that is consistent with guideline-recommended care the frontline (moving away from and taking the load from medical doctors)

Eg: Studies from Canada and the UK showing promising results.

23/25
Key messages:

PS: Congrats on making it this far👏

24/25
Key Messages

You are a champion for reading this 🙌

25/25
Key messages

💡Try to implement one of these in your clinical practice, and let me know how you go👊

Good people to follow are:
@PeteOSullivanPT @jpcaneiro @kieranosull @MaryOKeeffe007 @TrustmePhysio @PhysioNetwork @BrendanMouatt and many more I can't think of right now!