Low back pain: Can we mitigate the inadvertent psycho-behavioural harms of spinal imaging?

Re: Low back pain: Can we mitigate the inadvertent psycho-behavioural harms of spinal imaging?

Australian Journal of General Practice. Volume 47, No. 9, September 2018

In light of this recent article in the Australian Journal of General Practice regarding the use of imaging in the management of low back pain I was pleased to see the same messages and recommendations made to general practitioners in Australia as those recommended to physiotherapists.

The following tables outline the main recommendations:

Box 1. Guideline recommendations for the management of non-specific low back pain27

  • Exclude alternative diagnoses (ie red flags)
  • Avoid routine use of imaging
  • Offer high-quality education
  • Encourage return to normal activity
  • Encourage physical exercise
  • Advise use of simple analgesia
  • Use opioid analgesia cautiously

Box 2. Important messages for patient–clinician interactions 4,9,15,18–20,24 

  • Without clinical risk factors (red flags), serious pathology is uncommon.
  • Positive communication from the clinician has a significant impact on the patient.
  • Most non-specific low back pain improves after 4–6 weeks, and returning to normal activity as soon as possible is highly beneficial.
  • Evidence shows no benefit (and potentially negative impact) of routine imaging.
  • When imaging is expected, discussions of evidence-based guidelines to aid in education may prove helpful.
  • Radiological abnormalities are common and not often correlated with clinical presentation.
  • Imaging findings including ‘age-related changes’ should be explained to the patient with epidemiological context and with non-threatening language.
  • Referral to other health professionals may aid in patient education and improved recovery.

With the proliferation of private radiology companies offering direct referral for allied health, it is important that these messages reach general practitioners, allied health professionals and the general public.

I was also pleased to see the recommendation of a referral to other health professionals to assist the GP in managing the patient’s low back pain episode. Given the need for careful education and advice on keeping active, including exercising within the patient’s abilities and confidence, I see general practitioners could struggle to have the time in a consultation to do this.

In my experience, doing this over the average episode of care (4 to 6 weeks of recovery time) requires several appointments with a physiotherapist who is skilled in the contemporary assessment and management of spinal pain.

During this time the physiotherapist will also be able to counsel the patient to exercise on a regular basis to further improve their general health and minimise risk factors for other health conditions.

It is common for people with pain related movement dysfunction such as low back pain to reduce their general activity through fear of aggravating the pain.  Physiotherapists are experts in helping people to find ways to stay active despite painful conditions.  We can help them identify and break down the barriers to an active lifestyle.

Physiotherapists at Move for Better Health use a pain education strategy based on the work of pain neuroscientists, and can offer supervised exercise sessions in a variety of formats such as gym, Pilates, hydrotherapy, yoga and home exercises.

To ensure that home exercises are easy to follow we use online software called Physitrack which allows us to prescribe specific exercises for the individual and monitor their progress.  The patient is able to use an app to follow instructions (on a smartphone or ipad) via video and also to provide feedback to the physiotherapist regarding the completion of the exercises and pain scores if appropriate.  We also use this app to deliver educational material in written and video format to help reinforce the important messages we know will contribute to more positive outcomes for patients. In certain cases we also use specific outcome measures via Physitrack to assist in identifying yellow flags and also to monitor progress for reporting to third-party funders.

If you would like more information in regards to our management of low back pain please contact us at Move for Better Health.

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