Model of care for the management of low back pain – summary: consultation summary report

1. Introduction

The Model of care for the management of low back pain – summary (the Summary Model) is based on the NSW Government Agency for Clinical Innovation (ACI) 2016 Management of people with acute low back pain: model of care (the acute low back pain model of care).

SIRA partnered with the ACI to coordinate the revision, design, implementation and evaluation of the Acute Low Back Pain Model of Care resources so it could be applied in the NSW personal injury schemes (workers compensation and motor accident schemes). This also ensured consistency in practice between NSW public hospitals and primary and community care settings.

The Summary Model promotes consistency and best practice when caring for people experiencing low back pain, irrespective of whether it is a compensable injury or not and intends to reduce the utilisation of health services of little or no value (low value care) (see Box 1).

Box 1: Impact of the Summary Model on the NSW personal injury schemes

The model of care for the management of low back pain – summary (the Summary Model) will benefit over 18,000 people with lower back pain that enter the NSW personal injury schemes each year. The Summary Model will support people to receive value-based health care through early assessment, management, review and appropriate referral. By developing and implementing the Summary Model in the NSW personal injury schemes, people experiencing lower back pain will achieve better health and recovery outcomes and achieve more timely independence of the personal injury schemes.

1.1. Governance arrangements

SIRA convened its Back Injury Clinical Advisory Group (CAG), the NSW Agency for Clinical Innovation (ACI) and its expert networks to:

• review the acute low back pain model of care to develop an updated Summary Model
• ensure it included current research evidence and incorporates learnings of low back pain management in the NSW personal injury schemes
• ensure it aligned to the Australian Commission on Safety and Quality in Health Care’s (ACSQHC) Low Back Pain Clinical Care Standard (the Low Back Pain CCS).

The Back Injury Clinical Advisory Group (CAG) consists of:

• specialist musculoskeletal physiotherapist and manipulative therapist
• academic physiotherapist
• academic orthopaedic surgeon
• academic clinical psychologist in pain medicine
• neurosurgeon specialising in spinal surgery
• general practitioner
• sports and exercise physician.

SIRA sought clinical input from the CAG on the consultation feedback received relating to clinical practice or application (see section 2.1). After a series of consultations, the CAG provided recommendations to SIRA and the ACI.

1.2. About this public consultation

The consultation period ran from 16 August 2023 to 6 September 2023. SIRA invited submissions from:

• the people of NSW
• over 12,000 SIRA-approved allied health practitioners (AHPs)
• various health professional organisations and peak bodies, including the Australian Physiotherapy Association and Australian Psychological Society
• SIRA’s Workers Compensation Tripartite Committee
• SIRA’s Value-Based Health Care Advisory Committee
• over 80 licenced insurers operating under the NSW workers compensation and motor accident schemes.

The public consultation sought feedback from stakeholders on the implementation of the Summary Model and opportunities to support its adoption as best practice.

Stakeholders provided submissions through the SIRA website, NSW Government website and by emailing the Value-Based Health Care Initiatives and Projects team.

Public consultation was promoted through SIRA’s LinkedIn, ACI clinical networks and by electronic direct mail to all SIRA-approved AHPs, various peak bodies, workers compensation insurers and Compulsory Third Party insurers.

SIRA notes that the views expressed in published submissions are those of the submitters and do not necessarily represent the view of SIRA.

SIRA received broad acceptance and support from multiple stakeholders including health, insurance and academic sectors on the Summary Model following extensive consultation and engagement during its development.

Submission received:

SIRA received a total of 234 submissions from a diverse range of stakeholders, including:

• Australian Physiotherapy Association (APA)
• Australian psychological Society (APS)
• Australian Chiropractors Association
• Chiropractic Australia
• Exercise & Sports Science Australia (ESSA)
• Musculoskeletal Physiotherapy Australia
• Neurosurgical Society of Australasia
• Osteopathy Australia
• insurers
• individual health practitioners.

SIRA provides a breakdown of the submissions by stakeholder type in the table below:

Table 1: Number of submissions received from the public consultation on the implementation of SIRA's low back pain model of care

2. Key themes from stakeholder feedback

SIRA used the thematic analysis methodology in reviewing submissions to identify themes and subthemes. Two reviewers reviewed and coded submissions and identified seven overarching themes and subthemes.

Of the seven themes:

• two related to implementing the Summary Model and disseminating educational resources to health providers
• five related to clinical aspects of the Summary Model and treatment pathways.

A third reviewer checked the coding for bias and errors. A fourth reviewer ensured all relevant clinical themes were collated and presented to the CAG for review.

The five key themes relating to clinical aspects and presented to the CAG for consideration includes:

1. suggested terminology changes
2. clinical tools
3. access and definition of specialist services
4. suggested changes in pathways
5. limited follow up following initial consultation.

Sections 2.1.1 to 2.1.5 sets out these overarching themes and subthemes, including summaries of the feedback received and SIRA’s responses and rationale.

SIRA notes this summary report captures the major themes to arise as a result this consultation. Other issues were noted and discussed but may not be represented in this report.

2.1. Proposed amendments relating to clinical practice or application

SIRA identified five overarching themes in the consultation feedback relating to clinical practice or application.

Sections 2.1.1 to 2.1.5 sets out these overarching issues, including summaries of the feedback received and SIRA’s responses and rationale.

2.1.1. Theme 1. Terminology changes

In this theme SIRA received feedback expressing concern and support for specific terminology used in the Summary Model. The subsections below summarise the key feedback received, outcome and rationale for term.

Theme 1.1 Terminology changes relating to ‘physical therapies’ and ‘allied health professionals’

A number of submissions provided feedback relating to the terminology within the Summary model, some suggesting changes and some supporting the proposed terminology.

Change:

• term ‘physical therapies’ to ‘physiotherapy’
• the primary care team terminology ‘allied health professionals’ to ‘physiotherapist’.

Feedback theme 1.1.a – recommending a change in terminology in the Summary Model

Some stakeholders, in particular physiotherapists, proposed:

• changing the term ‘physical therapies’ to ‘physiotherapy’
• modifying the composition of the primary care team from ‘allied health professionals’ to ‘physiotherapist’
• physiotherapists expressed concerns about the potential risk to people receiving care from health providers not registered with or regulated by the Australian Health Practitioner Regulation Agency (Ahpra)
• they noted physiotherapists have a broad scope of practice enabling them to improve pain, functionality and quality of life through assessment, diagnosis, development of a treatment plan and providing appropriate care.

Physiotherapists were concerned that people receiving care for low back pain from health providers not registered with or regulated by Ahpra may not:

• receive comprehensive and holistic care because assessing and screening for complex pathologies, diagnosis or developing a suitable treatment plan may not be in their scope of practice
• have appropriate pathways or assurances to escalate issues when health care does not go to plan.

Feedback theme 1.1.b - supporting terminology in the Summary Model

ESSA, Osteopathy Australia, Chiropractic Australia and individual stakeholders supported using the term ‘physical therapies’ and therefore not changing the terminology in the Summary Model, as it refers to treatments that can be provided by multiple health professionals.

Their feedback indicated:

• the term ‘physical therapies’ recognises the value of all health providers in the multidisciplinary team to provide comprehensive coordinated care
• that models of care should focus on the knowledge, scope of practice and competencies of a health provider instead of professional titles
• that ‘physical therapies’ is a neutral term that supports people experiencing low back pain to pick a suitable health provider of their choice to deliver care that matters to them and meets their needs.

Using ‘physiotherapy’ instead of ‘physical therapies’ would unintentionally limit health provider choice, thereby reducing competition and options, particularly for people living in areas where there is a limited physiotherapy workforce.

Rationale for outcome and decisions

• The Summary Model provides the latest evidence-based guidance to general practice on the care pathway for managing low back pain. The focus of the care pathway is on the treatment (i.e., physical therapies) that a general practitioner should consider referring an injured person for and does intend to prescribe it.
• The purpose of developing the Summary Model was to review and update the 2016 ACI Acute Low Back Pain Model of Care. This involved reviewing this model of care against the latest evidence base and contemporary methodology for development of care pathways and practice. Specifically, this now relates to developing models of care and care pathways that refer to evidence base treatment types that promote good outcomes for people, instead of referring to a specific or individual health care provider.
• For further context, other key areas were also updated in the Summary Model from the original 2016 ACI Back Pain Model of Care, following a review of the evidence base, including: referral to cognitive behavioural approach and recommended pharmacological therapies.
• The SIRA methodology of a clinical guideline referring to treatment types rather than referring to a specific health provider, is consistent with how other clinical guidelines are developed in Australia. The Summary Model has been compared against Whiplash Associated Disorder Guidelines, fourth edition and Low Back Pain Clinical Care Standard. The Summary Model is consistent with evidenced based contemporary approaches across Australia.
• The ACI, who have partnered with SIRA to develop the Summary Model, also approach the development of their key health care guidelines, used across NSW Health, with the same methodology, i.e. referring to evidence based treatments rather than a specific health provider.
• The glossary has been updated to state ‘Physical therapy provider will be chosen based on scope of practice required for patient treatment approach.' This includes physiotherapists.
• Further, the CAG, ACI and SIRA also considered that limiting referrals to Ahpra registered health professionals could potentially disadvantage injured people living in rural and remote areas who may need to access services of non-Ahpra registered professional to assist in their back injury management as directed by their GP.
• Feedback received from the public consultation provided no evidence, and no additional evidence is known of by the ACI, SIRA or members of the CAG, that demonstrates that the quality or outcomes of care are impacted by the terminology in a model of care referring to treatment types versus referring to specific health professionals.
• The Summary Model is intended as a clinical guide for GPs and does not, in any way, hinder the ability for GPs to refer to physiotherapists, or any appropriately skilled health professional, to treat their low back pain patients.
• Considering the above factors, the Summary Model will retain the terminology of ‘physical therapies’, and therefore will not be replaced with a specific health professional (i.e. physiotherapist).

Theme 1.2 Terminology changes relating to ‘cognitive behavioural approach’

The APS requested the terminology in the Summary Model change from ‘cognitive behavioural approach’ to ‘psychological treatment using a cognitive behavioural approach’. No other submissions were received in relation to this terminology.

Change the term ‘cognitive behavioural therapy’ to ‘psychological treatment using a cognitive behavioural approach’.

Feedback theme 1.2 recommending a change in terminology in the Summary Model

• The APS proposed aligning the language used in the Summary Model to describe ‘cognitive behavioural approach’ with the original the Acute Low Back Pain Model of Care to ensure consistency between both documents.
• This would mean changing the term ‘cognitive behavioural therapy’ back to the original term, of ‘psychological treatment using a cognitive behavioural approach’.
• The APS rationale for the suggested change is ‘psychological treatment using a cognitive behavioural approach’ is a concept that is well understood by health providers.

Rationale for outcome and decisions

• The Summary Model provides evidence-based guidance to general practice on the care pathway for managing low back pain. The focus of the care pathway is on the treatment (i.e. cognitive behavioural approach) that a general practitioner should consider referring an injured person for. The Summary model does not focus on which health professional the GP should refer an injured person (i.e. referring to a psychologist).
• The SIRA methodology of a clinical guideline referring to treatment types rather than referring to a specific health provider is consistent with other clinical guidelines developed in Australia. The Summary Model has been compared and is consistent with the Whiplash Associated Disorder Guidelines (fourth edition), and the Low Back Pain Clinical Care Standard.
• The ACI, who have partnered with SIRA to develop this Summary Model of Care also approach their key health care guidelines, used across NSW Health, with the same methodology, i.e. referring to evidence based treatments rather than referring to a specific health provider.
• Based on the CAG’s clinical advice, using the term ‘cognitive behavioural approach’ avoids limiting this type of care to be provided by psychologists alone. A cognitive behavioural approach is recommended to be used by all practitioners engaging with the injured person to encourage patient compliance.
• The Summary Model supports people experiencing low back pain to receive cognitive behavioural therapy from a health provider of their choice that is competent or qualified to deliver this type of care.
• In addition, CAG, ACI and SIRA also agreed that by only referring to psychological treatment, this could disadvantage injured people living in rural and remote areas who may need to access services of non-Ahpra registered professional to assist in treating their GP directed back injury management.
• Feedback received from the public consultation provided no evidence, and no additional evidence is known of by the ACI, SIRA or members of the CAG, that demonstrates that the quality or outcomes of care are impacted by the terminology in a model of care referring to treatment types versus referring to specific health professionals.
• The Summary Model is intended as a clinical guide for GPs and does not, in any way, hinder the ability for GPs to refer to psychologists, or any appropriately skilled health professional, to treat their low back pain patients.

Considering the above factors, the Summary Model will retain the terminology of ‘cognitive behavioural approach’, and therefore will not be replaced with a specific health professional.

Theme 1.3. Terminology changes relating musculoskeletal specialist

The term ‘musculoskeletal specialist’ is ambiguous.

Feedback theme 1.3. rationale provided

Stakeholders noted the term ‘musculoskeletal specialist’ may not be appropriate in the Australian context, proposing more specific terms such as ‘spine specialist service’ or ‘musculoskeletal physiotherapist’.

Rationale for outcome and decisions:

The glossary provides a list of suggested specialists that may be considered ‘musculoskeletal specialists’. This list was not intended to be exhaustive. The explanation was intentionally broad to allow options for referral where there are issues with access, particularly in regional, rural and remote settings.

Theme 1.4. Terminology changes relating Principle 6 ‘active physical therapy encouraged’

The current wording of ‘Principle 6: Active physical therapy encouraged’ could be perceived to eliminate manual therapy as a treatment option.

Feedback theme 1.4 – rationale provided

The APA recommended amending Principle 6 of the Summary Model from the current: ‘Active physical therapy encouraged’ to the following:

‘Physical therapies will prioritise a patient-centred active approach, with or without evidence based and individualised manual therapy.’

Rationale for outcome and decisions

Principle 6 encourages an active approach to care. Manual therapy is not excluded and may be provided as a treatment option as appropriate. Therefore, the wording of Principle 6 does not require amending.

2.1.2. Theme 2. Clinical Tools

Theme 2. Clinical Tools

Concerns the Keele Subgroups for Target Treatment Back Screening Tool (KSBT) is not valid or reliable.

Feedback theme 2 rationale provided

Stakeholders expressed concerns about the approach to risk stratification in the Summary Model and the use of the KSBT. Stakeholders noted:

• there is limited evidence supporting measurements using the KSBT are accurate (poor validity)
• results from the initial study using the KSBT have not been replicated in other research (poor reliability).

Rationale for outcome and decisions

The KSBT is one of two tools that in the Summary Model that the health providers may choose to use. This tool is meant to be used to guide treatment approach. The use of this tool will be reviewed in future iterations of the Summary Model. SIRA will consider developing resources to educate health providers on the use of the two available tools which includes the KSBT and the Short-Form Orebro Musculoskeletal Pain Screening Questionnaire.

2.1.3. Theme 3. Access to and definition of specialist services

Theme 3.1. Referring to a pain specialist or clinic

Referral to a pain specialist at 12 weeks may be challenging due to limited access to appropriate services.

Feedback theme 3.1. rationale provided

Stakeholders questioned if referrals at 12 weeks were necessary. Feedback highlighted:

• challenges in accessing timely pain specialist services
• there are limited pain management programs and clinics in metropolitan Sydney and non-existent services in regional, rural and remote NSW communities
• stakeholders also noted that excessive wait times due to high demand and limited service availability poses a safety and quality risk.

Rationale for outcome and decisions

The Summary Model recommends referring people experiencing low back pain to a pain specialist at 12 weeks if the pain worsens or does not improve despite providing evidence-based care. This provides a pathway to escalate ongoing pain that does not improve to a trained specialist. The Summary Model aims to promote best practice and while considering feasibility cannot specifically account for local access issues.

Theme 3.2. Defining multidisciplinary pain management program

The multidisciplinary pain management program needs a clearer definition.

Feedback theme 3.2. rationale provided

Stakeholders recommended defining what a multidisciplinary pain management program is and what type of services it would provide. Their feedback suggested these types of pain programs may provide unconventional treatments or techniques that may be novel, but not be based on research evidence, and of little value.

Rationale for outcome and decisions

Based on the CAG’s clinical advice, most people experiencing low back pain are unlikely to require high-intensity pain management at the time of referral. This is something to be considered on a case by case basis depending on the personal circumstances of the injured person. Prescribing what comprises a multidisciplinary pain management program and the type of services it should offer is out of scope of the Summary Model.

2.1.4. Theme 4. Suggested change in pathways

Theme 4 Suggested change in pathways

Recommendations on pharmacological therapies in the pathways may be contradictory to Principle 8: Judicious use of complex medicines.

Feedback theme 4. rationale provided

Stakeholders noted the complex pharmacological therapies recommended at the two-week review seem to contradict Principle 8, which recommends careful use of complex medications.

Rationale for outcome and decisions

The Summary Model aligns to guidance in the Low Back Pain CCS on the judicious use of pain medicines by referencing the Therapeutic Guidelines^1,2. This ensures guidance on prescribed medication use for low back pain remains up to date with current evidence and therefore does not contradict Principle 8.

2.1.5. Theme 5. Limited follow-up following initial consultation

Theme 5. Limited follow-up following initial consultation

The recommended follow-up review intervals (visit numbers) in the pathways are not adequate to address patient needs.

Feedback theme 5. rationale provided

Stakeholders noted the visit numbers (first visit, second visit, third visit) recommending follow-ups to review the care provided to a person experiencing low back pain appear prescriptive and seem to focus on one initial visit and 3 follow-up visits (4 visits in total). They suggested 4 visits in total may not be sufficient to support the care needs of people.

Rationale for outcome and decisions

The Summary Model sets out recommended milestones when health providers are expected to comprehensively review the care provided to people experiencing low back pain across the care continuum. These milestones are at 2 weeks, 6 weeks and 12 weeks. At these milestones, health providers can decide which pathway to follow based on their assessment and diagnosis of a person’s health condition and progress to recovery. Health providers are expected to provide care on and after the initial review and recommended milestones.

2.2. Proposed amendments to implementation

Several non-clinical submissions fell under the overarching themes of disseminating the Summary Model and implementing it into practice. These were further broken down into subthemes, which included:

• suggestions for training
• barriers to uptake
• suggested changes to the key messaging
• the need for robust evaluation.

The insights and input received from stakeholder submissions have been analysed and will be integrated into SIRA’s strategic approach to implement the Summary Model including training content and resource development.

3. Next steps

SIRA is preparing to launch the Summary Model in February 2024.

To embed the Summary Model as best practice when caring for people experiencing low back pain, SIRA is:

• Updating its flagship Allied Health Practitioner Introductory Training Program. The online training program was developed in partnership with the Personal Injury Education Foundation. It was revised and launched in November 2023 to cover topics AHPs need to know to deliver value-based health care in the NSW personal injury schemes. This includes the Summary Model. Completing the online training program is the first step for AHPs who choose to become a SIRA-approved health provider.
• Partnering with the Royal Australian College of General Practitioners to develop 2 webinars to educate general practitioners. This work may extend to partnerships with NSW Primary Health Networks to broaden the reach and roll out of the Summary Model in primary and community care settings.
• Using the consultation feedback received to develop a strategy to co-design educational resources specifically for AHPs and insurers.

Educational resources which are intended to be published on SIRAs website and disseminated where practical will include:

• For AHPs
  • webinars tailored to build AHP capability in the Summary Model
  • case studies on the benefits of using the Summary Model and how it will improve outcomes for people experiencing low back pain.
• For insurers
  • webinars
  • fact sheets
  • frequently asked questions.
• For people experiencing low back pain
  • fact sheet translated into 14 community languages.

For more information on the Summary Model or outcomes of the public consultation process, email the project team at [email protected] or call 13 10 50.

References

¹Pain and Analgesia Expert Group. Therapeutic guidelines: pain and analgesia, version 7. Melbourne: Therapeutic Guidelines Limited; 2020.

²Rheumatology Expert Group. Therapeutic guidelines: rheumatology, version 3. Melbourne: Therapeutic Guidelines Limited; 2017.