Pathways for Managing Low Back Pain
The Collaborative Efforts of Four PMC PIs Yield a Paper & a Call to Action
Pain • December 2020
Many of the best practice guidelines for low back pain treatment involve evidence-based therapies often not integrated into a single clinical setting, meaning that treatments like physical therapy and chiropractic care are often delivered outside of the majority of first-line access points in United States healthcare systems. The result is that care coordination, access, and follow-up become challenging for both patient and care providers. For many conditions, health care providers order tests and imaging, knowing that patients can access these services, results can often be coordinated, and these results will influence clinical decision making; however, pain is complex, and therefore, it is much harder to coordinate diagnosis, effective treatments and care management outside of an integrated care setting. While the VA and Military healthcare systems have some facilities that offer a more holistic one-stop approach for evidence-based pain therapies (and the coordination and quality assurance of those therapies), for those seeking treatment for pain, there remains a division between what “therapies are available, recommended and effective, and what we traditionally think of as health care [services],” says Susan Nicole (Nicki) Hastings, MD, one of the co-authors of a paper published in Pain’s December 2020 issue.
Dr. Hastings, who is co-PI of the PMC AIM Back Trial with Steven George, PT, PhD, co-authored the piece addressing pathways to better pain management with Dr. George, as well as Julie Fritz, PT, PhD, FAPTA (The SMART LBP Trial), and Christine Goertz, DC, PhD (VERDICT Trial). The four authors, all with trials in the PMC, were either re-united or better acquainted with one another through their work within the Pain Management Collaboratory, and harmonized their respective expertise areas to bring the Pain paper to fruition. Co-author Dr. Julie Fritz notes that “one of the really nice opportunities that has grown out of the PMC is either re-establishing or forming new collaborative relationships with the other investigators involved in various projects, and the paper that Steve George, [Nicki Hastings, and Christine Goertz and I collaborated on] is a great example. In this author group, a couple of us are physical therapists, [one is a] chiropractor, and one a primary care provider.” In their conversations, the four recognized a need for better pathways for pain management in the United States, given the divide between the way pain care was actually delivered and the recommended, evidenced-based practices and guidelines set forth in the scientific literature. To address this gap, the four posed the question, “How should care be organized so that the patient experience of flowing through care is sensible and evidence-based to the extent that we can make it?” Fritz explains.
All of the Pain Management Collaboratory trials are focused on delivering non-drug options to effectively ease the experience of pain in Veterans and active Service members. No matter the type of patient, or where the patient enters the system for their pain, treatment options need to be organized and delivered in such a way that it is easy for patients to receive and comply with treatments, and for providers to follow up. Hastings, a clinician with a focus on geriatric care as well as a researcher, poses the question, “Is it really realistic for every individual primary care provider to be the expert on how to access all of these different types of therapies, you know, in his or her community?”
This is where the authors propose a health navigator—a local resource expert who is trained in how to factor in an individual’s previous experiences and preferences when making recommendations—for developing a pain pathway for the individual. A pain care navigator could be a chiropractor, a nurse, a physical therapist or other health care provider that one might see as the first stop in seeking help for their pain. “We are really testing this idea of individualization so that we ensure optimal adoption of therapies for pain,” says Dr. Hastings. Developing an effective treatment model for pain that takes into account patient preferences, lifestyle, and current needs and is more than just a “cookbook kind of an approach.” This approach acknowledges that patients enter the healthcare system from many different starting points, and so there is a need to train providers from a number of different disciplines to organize, plan, and deliver individualized care options.
In addition to navigating through different treatment modules, other barriers to effectively managing a pain treatment plan include cost, the need for more providers (especially ones embracing a multimodal, individualized pain care plan), and appropriate delivery of treatments. “One of the biggest barriers right now has to do with payers who are willing to pay high dollars for spine surgeries or injections, but are less willing to cover guideline-concordant treatments such as spinal manipulation, acupuncture, cognitive behavioral therapy and yoga,” says Christine Goertz, DC, PhD. “I think until we are better at embracing payment models that put an emphasis on conservative care and reward all of those involved, we’re going to continue to struggle. Fortunately, I see some signs that our healthcare system is changing in this direction.” Factoring in access for multiple providers, perhaps from different payees, to deliver and treat in a unified way ends up being more than about the cost. “It’s really about the coordination,” Dr. George explains. “Can we coordinate this at the trial site and do we have the personnel to deliver it? One of the things we’ve learned in designing our trial is that you have to temper your expectations with what can be coordinated, either across disciplines or even within disciplines. If a plan has too many moving parts, the system, as it exists now, is not going to be able to coordinate it.”
Ensuring patient understanding and involvement in their pain management can also be a challenge. Here, again, every patient is unique in that they have different experiences, levels of fear in regard to their pain, and different levels of health literacy, which impacts their health outcomes. “It’s really important to have the patient involved in the process [of developing a pain management plan],” Dr. Goertz underscores. “When it comes to low back pain, we know that people who are more frightened by their pain can have worse outcomes. Anything that can help patients better understand their pain can paradoxically lead to less pain in the future, which is why patient education is really important.” Additionally, healthcare providers need to be well-versed in effective communications techniques to ensure that patients understand, feel supported, and are involved in the decision-making process. Conversations should focus on lessening the experience of pain and increasing understanding, as opposed to exacerbating fear. “This is important with healthcare delivery in general, but especially important with people who have low back pain,” Goertz says.
Dr. Goertz also pointed to a Gallup study that asked individuals which types of providers they thought were the safest and most effective for managing back and neck pain. Participants indicated that physical therapists and chiropractors were the safest and most effective; however, when asked which provider they would see for pain management, more than half said that they’d prefer to see a medical doctor first. “It is crucial that clinicians are aware of coordinated care guidelines for back and neck pain and are able to facilitate access to that care for their patients,” Goertz asserts. “For instance, the American College of Physicians recommends that patients and their clinicians consider nonpharmalogical treatments including acupuncture, massage, yoga, Tai Chi and spinal manipulation before prescription medication for low back pain.” Historically, these treatments have had less emphasis during clinical training for many health care providers, and facilitating access and coordinating the follow-up can be challenging. Additionally, a patient’s insurance may not cover all the recommended considerations, and facilitating access and coordinating the follow-up can be challenging.
At the center of evaluating pathways for pain management is a call to action to put more thought and organization into what happens to patients when they first seek care for pain and the long term consequences of the patient’s earliest experiences with the health care system. “It takes a really intentional effort to say, ‘What are the first set of decisions that need to be made? And then what are the next decisions that need to be made?’” observes Dr. Fritz. To avoid the early intensification of pain care, which results in greater expense and invasiveness escalating rapidly, we need to ensure that the evidence-based guidelines are getting put into practice, and patients understand that managing pain isn’t a linear process where a person goes in to see a provider, gets a diagnosis, gets a treatment, and the pain goes away. Communication among patient and providers is essential to get on the right pathway for pain management. “If we can be more aligned in our messaging around back pain in the community—before individuals become patients, where they may not yet be experiencing back pain, or before it affects their ability to function—it can help set expectations and set up the conversation with care providers when they do come in,” says Dr. Hastings. “The first thing we ought to be reaching for are these non-drug therapies, and reserving imaging for specific cases since it’s not going to change what we do in the majority of cases.”
For Further Reading:
George, S. Z., Goertz, C., Hastings, S. N., & Fritz, J. M. (2020). Transforming low back pain care delivery in the United States. Pain, 161(12), 2667–2673. doi: 10.1097/j.pain.0000000000001989
Fritz, J.M., Rhon, D.I., et al. (2020, December 10). A sequential multiple-assignment randomized trial (SMART) for stepped care management of low back pain in the Military Health System: A trial protocol. Pain Medicine, 21(2), Pages S73–S82, https://doi.org/10.1093/pm/pnaa338
George, S.Z., et al. (2020, December 10). Improving Veteran access to integrated management of back pain (AIM-Back): Protocol for an embedded pragmatic cluster-randomized trial. Pain Medicine, 21(2), S62–S72. https://doi.org/10.1093/pm/pnaa348