This lecture was given by Professor Gary Macfarlane, Professor of Epidemiology at the University of Aberdeen, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. Professor Macfarlane is introduced by Dr Colin Rae. The lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care". www.wspg.org.uk

1. Can Primary Care Provide Effective Management of Chronic Pain? Gary J Macfarlane Professor of Epidemiology

3. Lifetime prevalence of back pain Papageorgiou et al, 1995 Population: Manchester, UK (N=7669) South Manchester LBP study 1991-3 0 10 20 30 40 50 60 70 80 18-29 30-44 45-59 60+ Prevalence (%) Lifetime prevalence 1-year prevalence 1-year consultation

6. Low Back Pain Guidelines National guidelines on primary care management in 12 countries Differences : development groups, target populations, methods used

7. Diagnostic Triage Non-specific back pain Nerve root pain Possible serious spinal pathology (“red flag”)

8. Management of non-specific back pain Gradual and early activation Avoidance of bed rest Acknowledge role of psychosocial factors Koes et al, 2001

10. Environment 0 10 20 30 40 50 60 70 80 I/II Professional III Non-Manual III Manual IV/V Non-Skilled Prevalence (%) Palmer et al, 2000 Social class

11. Environment Obesity Lack of exercise Cigarette smoking Lifestyle

12. Environment Workplace: Mechanical factors

13. Mechanical (injury)

14. Environment Workplace: Psychosocial factors

18. Psychological predictors of persistence: Systematic Review Strong evidence Psychological distress Depressive mood Coping strategy Somatisation Pincus et al, 2002 Evidence Weak evidence

25. BMJ 2005; 330: 674 Best “Usual care” +/- Exercise +/- Manipulation

26. LBP Functional Outcome

27. BMJ 2004; 329: 708

28. Baseline 2 6 12 months Change: Roland and Morris Disability Qu . Advice Physiotherapy

29. Lancet 2005; 365:2024

30. Pain management (n = 201) Manual Physiotherapy (n = 201) Completely/ much better (%) 68 Satisfaction with treatment (0-100 mm) 93 69 93 LBP Functional Outcome

31. BMJ 2005; 331:84

32. Psychosocial Interventions v. Usual Care 0 3 6 9 12 15 18 21 24 0 3 6 9 12 Months Usual care Roland and Morris Disability Psychosocial interventions

34. Roland and Morris Disability Score Change 3 6 9 12 15 Months Group Sessions better Usual Care better LBP Functional Outcome 12 9 6 3 0 -3 -6

35. 3 6 9 12 15 Group Sessions better Usual Care better 30 20 10 0 -10 -20 -30 Pain (Vas) Change Score LBP Pain Outcome

38. Informing management: Re-think expectations ? Interventions - individual/populations - target risk factors - patient beliefs Re-examine aetiology of onset and outcome ? Improved measurement of known risk factors ? Future Directions in Management

39. Informing management: Re-think expectations ? Interventions - individual/populations - target risk factors - patient beliefs Re-examine aetiology of onset and outcome ? Improved measurement of known risk factors ?

42. Back Beliefs: Population-level

45. Back Beliefs: Population-level Back Pain Beliefs Questionnaire Intervention 26.1 26.3 26.2 26.3 NSW 28.8 29.7 28.4 26.5 Victoria 3 years later After During Before

46. Informing management: Re-think expectations ? Interventions - individual/populations - target risk factors - patient beliefs Re-examine aetiology of onset and outcome ? Improved measurement of known risk factors ?

47. The STarT Back Screening Study S ub-grouping for Tar geted T reatment in Low Back Pain The STarT Back Team: EM Hay, S Somerville, JC Hill, E Mason, C Vohora, T Whitehurst, G Sowden, K Konstantinou, CJ Main, K Dunn, J Bailey, C Calverley University of Keele

53. STarT Back Screening Tool Patient with prognostic indicators of persistent LBP A mix of different prognostic indicators Patient without prognostic indicators of persistent LBP Low risk 26% High risk 26% Medium risk 48% High psychosocial prognostic indicators

55. Informing management: Re-think expectations ? Interventions - individual/populations - target risk factors - patient beliefs Re-examine aetiology of onset and outcome ? Improved measurement of known risk factors ?

57. Johnson et al, 2007 Spine (in press)

58. -30 -20 -10 0 10 20 30 3 6 9 12 15 Group Sessions better Usual Care better Pain (Vas) Change Score LBP Pain Outcome: Patient Preference

59. Informing management: Re-think expectations ? Interventions - individual/populations - target risk factors - patient preference Re-examine aetiology of onset and outcome ? Improved measurement of known risk factors ?