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Prof Christopher Maher cmaher@george.org.au Director, Musculoskeletal Division Professor, Faculty of Medicine, Universit

Prof Christopher Maher cmaher@george.org.au Director, Musculoskeletal Division Professor, Faculty of Medicine, University of Sydney. Latest research Red/yellow flags Simple well delivered treatments Current practice may not always be best practice: why?. Musculoskeletal best practice.

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Prof Christopher Maher cmaher@george.org.au Director, Musculoskeletal Division Professor, Faculty of Medicine, Universit

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  1. Prof Christopher Maher cmaher@george.org.au Director, Musculoskeletal Division Professor, Faculty of Medicine, University of Sydney

  2. Latest research Red/yellow flags Simple well delivered treatments Current practice may not always be best practice: why? Musculoskeletal best practice

  3. Diagnosis/Prognosis Most LBP is benign Do not routinely order imaging Red flags to exclude serious pathology Screen for yellow flags Treatment-acute First line care Advice & Paracetamol Second line care NSAIDs Muscle relaxants or opioids Physical therapies Persistent pain exercise Acute LBPGuideline endorsed Management

  4. How prevalent is serious disease? • Inception cohort study of 1,172 consecutive patients with acute LBP • First consultation to primary care for this episode • 25 red flag screening questions • Follow up for 12 months Henschke et al. (under review)

  5. Initial episode of care Follow-up over one year Randomly selected for review at 12/12 +ve or ? +ve or ? Rheumatological review • Serious pathology • Cancer • Fracture • Infection • Inflammatory disorder • Cauda Equina Syndrome • Other • Not serious pathology

  6. Serious pathology in Sydney primary care • Only 11 confirmed cases serious pathology (< 1%) • 8 fracture • 1 cauda equina syndrome • 2 inflammatory arthritis • 0 infection • 0 cancer Henschke et al. (under review)

  7. Detection of vertebral fracture Presumed pre-test probability 1.0% Four red flags: a) female gender b) age > 70 years, c) significant trauma (major in young, minor in elderly) d) prolonged use of corticosteroids. Henschke et al. (under review)

  8. Prognosis of Acute LBP • ‘Majority recover within 3 months… however milder symptoms often persist’ • (Aust Guideline) • ‘90% of patients will recover spontaneously within 4 weeks’ • (US Guideline)

  9. Sydney primary care • Inception cohort study of 973 patients presenting to primary care with LBP < 2 weeks duration • Follow up at 6 weeks, 3 months, and 12 months (< 3% dropout) • Sampled three dimensions of recovery: return to work, interference with function due to pain, and pain status Henschke et al. BMJ (2008)

  10. Three pictures of recovery from LBP No disability Normal work status Pain-free

  11. Yellow flags(adverse prognostic factors) • Older age • More intense pain • Longer duration of low back pain • More days of reduced activity • Patient reports feeling depressed • Patient believes pain is likely to persist • Compensable low back pain Henschke et al. (2008)

  12. Is advice and paracetamol sufficient?Should I consider spinal manipulation &/or NSAIDs?

  13. Is advice and paracetamol sufficient?Should I consider spinal manipulation &/or NSAIDs? • Baseline care • Advice & paracetamol Hancock et al. Lancet (2007)

  14. Persistent low back painExerciseor advice? Pengel et al. Annals Intern Med (2007)

  15. Research Plan • Placebo controlled RCT • Exercise and advice • Exercise (and advice placebo) • Advice (and exercise placebo) • Double placebo Pengel et al. Annals Intern Med (2007)

  16. Results at 6 weeks: Pain (0 to 10) Pengel et al. Annals Intern Med (2007)

  17. Does it matter which exercise?

  18. Desirable characteristics for chronic LBP exs program Hayden et al Ann Intern Med 2005

  19. Exercise for chronic LBP% reduction in pain (group mean) • Supervised exs in gym vs gym pass(Reilly et al 1989) • exp: 58% • control: 3%

  20. Current practice Management of new cases of LBP in Australian primary care

  21. Growth in evidence

  22. The graduate of 1980…. ~4% of today’s evidence (441 trials)

  23. The graduate of 2000…. ~48% of today’s evidence (5,301 trials)

  24. Physiotherapy Evidence Database PEDro

  25. Origin of PEDro searches

  26. Value of reviews & guidelinesCumulative no of LBP exs trials Deyo 1983 Koes 1991 Van Tulder 2000 Hayden 2005 Source PEDro 12/08/08

  27. Musculoskeletal best practice • Musculoskeletal best practice • Simple may be best • Well delivered treatments • Current practice may not always be best practice • Growth in evidence • Challenges & opportunities

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