4/27/2012
SECONDARY PREVENTION OF
CHRONIC MUSCULOSKELETAL
PAIN
Mark Bishop, PT, PhD
Public Health Seminar, 2011
Up front acknowledgements


Steven George
Micheal Robinson
Today’s agenda

The problem of chronic musculoskeletal (MSK) pain

Strategies for intervention for chronic MSK pain

Future collaborations between PH and HP
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Pain is everywhere

Primarily protective

Often peaks and resolves consistent with inflammation

Essential for survival
100
80
60
40
20
0
Baseline
24hr
48hr
96hr
w eek1
Prevalence of musculoskeletal pain
Pain Location 12‐mth prevalence Neck Shoulder High back Elbow Wrist/Hand Lower back Hip Knee Ankle Foot 
31.4 30.3 18.8 11.2 17.5 43.9 12.8 21.9 9.2 9.5 Point prevalence 20.6 20.9 901 7.5 12.5 26.9 9.1 15.2 4.9 6.5 Prevalence of chronic pain
14.3 15.1 6.2
5.3 9.3
21.2 7.4 11.7
3.5 5.0 Do you have pain?

Picavet, Pain, 2003
Prevalence of musculoskeletal pain
Picavet, Pain, 2003
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What about in the USA?
Rising prevalence
Rising prevalence

From1992 to 2006 prevalence of low back pain
increased by 162%
increases of 219% in the 45 to 54 year-old age group.
among
g females aged
g 21 to 34 it increased 320%
 among males from age 45 to 54 it increased 293%.




Freburger, Arch Int Med, 2009
At least in North Carolina
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Chronic pain

Pain and disability


Strongly associated for most anatomical regions
Costly societal problem

Estimated annual cost of pain using MEPS 2008 is $560
$560–
635 billion in 2010 dollars.


combines the cost of health care ($261–300 billion) and the cost
of lost productivity ($11.6-12.7 billion) attributable to pain.
Thought to be a conservative estimate


excludes institutionalized individuals (including nursing home
residents and corrections inmates), military personnel, and personal
caregivers
excludes the emotional cost of pain.
Chronic pain

Chronic pain can be conceptualized as a public health
challenge for a number of important reasons having to
do with prevalence, seriousness, disparities, vulnerable
populations, the utility of population health strategies,
and
d the
h importance
i
off prevention
i at both
b h the
h
population and individual levels.



IOM Report, Relieving Pain in America, 2011
Pain that persists
Definitions vary but 3 months is most common
Scope of problem

Pain affects more Americans than diabetes, heart disease and
cancer combined. The chart below depicts the number of chronic
pain sufferers compared to other major health conditions.
Condition
Chronic Pain
Diabetes
Heart Dis.
Stroke
Cancer
Number of Sufferers
116 million
25.8 million
16.3 million
7.0 million
11.7 million
Source
Institute of Medicine
American Diabetes Association
American Heart Association
American Cancer Society
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Strategies for prevention




Examples from the literature regarding low back
pain
Primary
Secondary
Tertiary
Strategies for prevention

Primary prevention



Secondary prevention



development of a disease
health promotion activities are primary preventive
measures.
early disease detection
opportunities for interventions to prevent progression of
the disease
Tertiary prevention

reduce the impact of established disease by restoring
function and reducing complications
The time to recovery from low back pain presented in general practice.
Workers still on sick leave
Adapted from Watson 1998
Patients with chronic LBP
~5% of workers will still be off work
van den Hoogen H J M et al. Ann Rheum Dis 1998;57:13-19
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4/27/2012
The time to recovery from low back pain presented in general practice.
1
2
3
van den Hoogen H J M et al. Ann Rheum Dis 1998;57:13-19
The time to recovery from low back pain presented in general practice.
1
2
3
van den Hoogen H J M et al. Ann Rheum Dis 1998;57:13-19
Primary prevention (before pain onset)
Ergonomics
Exercise
 Education


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Primary prevention: Ergonomics

Workplace interventions
Changes in environment
Changes in work organization
 Changes
Ch
iin workk conditions
diti



Examined across multiple body regions
van Oostrom et al. Workplace interventions for preventing work disability. Cochrane
Database of Systematic Reviews 2009, Issue 2. Art. No.: CD006955.
DOI:0.1002/14651858.CD006955.pub2.
Primary prevention: Ergonomics

Workplace interventions

Speed return to work
BUT

no effect on health-related outcomes
Primary prevention: Ergonomics
Back
 “The results concerning prevention for subjects not
seeking medical care are sobering. “
 Insufficient evidence for ergonomic modifications to
prevent pain

Linton and van Tulder. Spine. 2001 Apr 1;26(7):778-87
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Primary prevention: Ergonomics

interventions not effective in preventing LBP

stress management, shoe inserts, back supports and
reduced lifting programs
 not
found to reduce either incidence or severity of BP
episodes compared with controls
 In fact negative trials identified

Bigos et al. Spine J. 2009
Primary prevention: Exercise
Primary prevention: Exercise
Back
 Limited evidence for effectiveness of exercise for the
prevention of LBP
 Strong
g evidence that exercise reduces the intensity
y of
and episode of LBP
 Strong evidence that exercise reduces activity
interference from LBP
 Weak evidence for measures such as costs of LBP

Bell and Burnett. J Occup Rehabil 2009

Linton. Spine. 2001 Apr 1;26(7):778-87
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Primary prevention: Education
Primary prevention: Education



A multimedia campaign 1997-1999 in Victoria,
Australia, positively advised patients with back pain to
stay active and exercise, not to rest for prolonged
periods, and to remain at work.
Compared FABQ
FABQ, physician beliefs in NSW and
Victoria
There were large statistically significant improvements
in back pain beliefs over time in Victoria but not in New
South Wales

Buchbinder Spine 2001
Primary prevention: Education



Among those who reported back pain during the previous
year, fear-avoidance beliefs about physical activity
improved significantly in Victoria but not in New South
Wales
GPs in Victoria reported
p
significant
g
improvements
p
over time
in beliefs about back pain management, compared to NSW.
Accompanied by a decline in related workers’ compensation
claims and health care utilization during the campaign


Buchbinder Spine 2001
Difference persisted for years afterwards

Buchbinder Spine 2005, 2010
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Secondary prevention


Prevent the progression to a chronic pain condition
Implications

Intervention during the acute and subacute phases of
p
pain
The time to recovery from low back pain presented in general practice.
1
2
3
van den Hoogen H J M et al. Ann Rheum Dis 1998;57:13-19
Secondary prevention


Prevent the progression to a chronic pain condition
Implications

Timing of intervention during the acute and subacute
phases of pain
p
p

Appropriate treatment for patient characteristics
 ‘Matched’
treatment
 Screening
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Secondary prevention

Identify subgroups of patients

IOM Recommendation

Screening for risk factors for chronic LBP

Examples from Physical Therapy literature
Matched treatment?

Large cohort studies in 20th century treated patients
with LBP as homogenous group



All patients enrolled and treated with same intervention
Generally large variability in clinical responses to
i t
intervention
ti th
thatt iintervention
t
ti
Result?

small effect sizes and conclusions about the effectiveness
or lack-there-of
 eg
AHCPR guidelines
Matched treatment



However, clinical practice is to match treatment to
individual characteristics of patients
In Physical Therapy literature:
clinical prediction rules developed
Manipulation
Centralization
 Stabilization


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Specific Treatment Model - manipulation
4 Factors:
 Recent onset (<16 days)
 Low fear (FABQ <19)
 No
N symptoms
t
below
b l knee
k
 Lumbar stiffness
 Good hip IR (>35 deg)
+LR for >50% in 48 hours = 13.2
Two-dimensional graphical representation of the 3-way clinical prediction rule × treatment
group × time interaction for the Oswestry Disability Questionnaire (ODQ) score (PԜ< 0.001).
Childs J D et al. Ann Intern Med 2004;141:920-928
©2004 by American College of Physicians
Remember this?
Workers still on sick leave
Adapted from Watson 1998
van den Hoogen H J M et al. Ann Rheum Dis 1998;57:13-19
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Remember this?
Workers still on sick leave
Adapted from Watson 1998
van den Hoogen H J M et al. Ann Rheum Dis 1998;57:13-19
Matched treatment



However, clinical practice is to match treatment to
individual characteristics of patients
In Physical Therapy literature:
clinical prediction rules developed
Manipulation
Centralization
 Stabilization


Adjusted modified Oswestry Low Back Pain Disability Questionnaire (ODQ) scores at each
assessment point.
Browder D A et al. PHYS THER 2007;87:1608-1618
©2007 by American Physical Therapy Association
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Does this help?

So, while this sounds great, does it make a
difference to the public health problem?
Does this help?
Matching treatment and future healthcare costs (Fritz et al, 2008)
 Four hundred and seventy-one patients

28.0% received adherent (matched) care





fewer physical therapy visits (mean difference 1.3 visits)
lower charges (mean difference $167)
greater improvement in pain (mean difference 12.3%)
greater improvement in disability (mean difference 17.6%)
During the year after discharge there was lower likelihood of



prescription medication
imaging
epidural injections
Caveat Emporum


Preliminary evidence
Only ‘manipulation’ rule is validated in subsequent
studies
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Screening for risk factors

In studies predicting long-term musculoskeletal pain
outcomes, the strongest predictors are
Anatomical factors (i.e. disc herniation, degeneration)
Clinical factors ((i.e. range
g of motion,, strength)
g )
 Demographic factors (i.e. sex, age)
 Psychological factors (i.e. satisfaction, anxiety)


Screening for risk factors

In studies predicting long-term musculoskeletal pain
outcomes, the strongest predictors are
Anatomical factors (i.e. disc herniation, degeneration)
Clinical factors ((i.e. range
g of motion,, strength)
g )
 Demographic factors (i.e. sex, age)
 Psychological factors (i.e. satisfaction, anxiety)


Screening for risk factors

Pain-related psychological factors predict a variety
of outcome measures related to chronic pain

Pain intensity and Disability
 1-year

outcomes (Burton et al, 1995)
Healthcare utilization
 more
strongly predicted by work and psychological factors,
than physical factors (Boos et al, 2000)
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Screening for risk factors

Pre-pain/injury levels of emotional and
psychological distress may enhance or prolong pain


Not the cause
Screening for these is recommended by many
national and international taskforces

‘Flags’ system
But what to screen?
Leeuw et al 2007: Fig. 1. The fear-avoidance model of chronic pain.
What to screen?

Questionnaires

Single construct
 Depression
 Fear
 Anxiety
 Catastrophizing

Multiconstruct
 Start-Back

tool
Developed for general practice in UK
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Other body areas

Fear predicts outcomes in:
Lumbar spine
Cervical spine
 Knee
 Shoulder



Blend approaches

George and Bishop, 2008
Will this help?

Another area for collaboration between PH and HP
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Will this help?

Busch et al, 2011
PT
CBT
 Combined
C
 Control



Sick leave and healthcare costs for 10 years
Will this help?

Busch et al, 2011
Will this help?

Busch et al, 2011

Healthcare costs over 10 years
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Summary




Chronic pain is a public health problem
Matching (conservative) interventions seems to
decrease pain, disability and costs
Screening for factors know to prolong a painful
episode
Needs


Comparative effectiveness
Practice-based research
Thank-yous

UF
Michael Robinson
 Steve George
 Joel Bialosky
y
 Jason Beneciuk
 Carolina Valencia
 Maggie Horn
 Meryl Alappattu
 Charles Gay


University of Utah and
Intermountain Health


Julie Fritz
Gerard Brennan
Questions?
19