COCA - December 2002 Newsletter: Future of Low Back Pain Management

At the recent October COCA Conference held in Melbourne, this question was posed to 5 manual therapy practitioners on the Grand Rounds Panel. The responses from our panel included an osteopath, a chiropractor, a physiotherapist/chiropractor and 2 physiotherapists.

Osteopath Lainie Cameron opened the discussion revealing her talents as actor, clairvoyant and osteopath.

“The good doctor, Peter Werth, crossed my palm with silver and asked for a prediction. The future of back pain management…..Difficult, very difficult….I must consult the orb…
I must clear my mind, and wait, and feel the answers coming to me from the depths of the time yet to come.
Ah, yes, I see it now.
But I fear you will not like what you see. But tell it I must… Brace yourself, for I see two futures, and lo, you must choose.
Your art, your skills, the trade for which you labour, will move from being a secret craft taught in hallowed halls, to a science open to critical scrutiny.
The transition has already begun.
The critics will come from within…
And from without.
No one will escape their prying eyes. When the scrutineers come, you have choice.
Listen, or not listen. Change, or not change. Grow, or not grow.
Before the criticisms, it did not matter.
You could be whatever you wished, do whatever you wanted, and believe what you desired.
When the scrutineers come, you have a choice.
To ignore the critics may bring your peril. Doomsayer am I.
If you do not heed the scrutineers, your art may be lost to you.
To heed the critics may not satisfy. Doomsayer am I. If you do heed the scrutineers, you may be forced to specialise your art, and relinquish title to territory previously your own.
Save me, you cry. Save me. Draw me back from the brink of this horrible choice. Is there no other way?
Yes, my dear seeker, there is another way…It is neither an easy path, nor a sure one, but it is a position of power.
Learn. Learn the art of the scrutineer. Learn the art of science. Learn to be a critic of your own art, and make your own changes before the scrutineers force your future.
Look inwards dear seeker. View yourself. Critique yourself. Be your own scrutineers. Change yourself. Create your own future. Control your own destiny.”

Standards of practice will rise. This will be achieved by increased time spent with patients and a more uniform approach to patients through the use of guideline development (homogeneity).

Evidence will define practice more and more and in every respect. Ideology and dogma will still exist but it will be quarantined and regarded as an historical curiosity. As the evidence grows on best ways to diagnose and manage back pain it is likely that more of us will begin to expand our management armamentarium including the prescription of medication.

Chiropractors and osteopaths in a decade will be more relevant and respected. Further good news is that fees will rise. Not just commensurate with the consumer price index but with increasing standards of practice and effectiveness.

There is increasing evidence of the impact that the active components of the musculoskeletal system have on the clinical course of low back pain. It is likely that management of low back pain in ten years time will involve a greater use of interventions that modify the strength, endurance and patterning of low back related muscles. In particular, it is likely that the current models of low back stabilisation will have been elaborated and that the role of interventions that influence the patterning of muscle contraction will have been clarified.

There will be more primary-care based research in low back pain, and as most low back pain is seen in primary-care settings, this will result in more clinically-relevant research. It will also result in a greater collaboration between researchers and primary-care clinicians, which will impact both clinical practice and the research agenda. It would be ideal if this collaboration also resulted in an on-going research effort that attempts to answer a few strategic and significant clinical questions.

Unless there is a shift in the way the community perceives and administers the medicolegal issues of causation, liability and compensation, there will be an increase in the clinical demands of documentation, measurement and informed consent. Defensive medicine will modify clinical practice by (1) influencing the extent to which patients are invited to, and required to, participate in clinical decision-making, and (2) making clinicians risk-averse.

As it is likely that there will always be a disparity between the knowledge base and experience of the clinician and that of the patient, the community will need to decide what role trust should play at the clinical interface. The community will also need to decide if the way that litigation modifies clinical practice results in better patient outcomes.

Some pundits predict that in an ideal world of evidence-based practice, all healthcare provided would have been shown to do more good than harm in randomized controlled trials (RCT’s) and I would argue shown to achieve comparable outcomes in clinical practice. While therapies of unknown benefit would only be offered as part of an RCT. Realistically, I think there will still be a large number of therapies of unproven or dubious benefit that are provided because people are prepared to pay for them. However, they will not be funded by the public purse or by insurers.

Clinicians and patients will have much greater access to the research evidence. The Federal Minister for Health is proposing to give all Australians access to the Cochrane Database of Systematic Reviews. A consequence of better information access will be that patients will expect a greater role in decision-making about their healthcare, and may be more litigious. For example, it would not be impossible that patients would sue for recovery of costs should they discover they have been “sold” a treatment that had been convincingly shown to be ineffective, or to be less than effective than an alternative.

The flip-side of this greater access to information may be that the power-distance between patients and clinicians will be even further reduced, and the latter will need to practice more defensively. It may be that in negotiating the therapeutic approach, the clinician will have to say something like: ‘’The evidence is that this therapy will work this percent of the time, with these complications, this frequently; what do you want to do?’’.