Chairs: Paulo Ferreira (University of Sydney), Manuela Ferreira (University of Sydney), Helen Slater (Curtin University), Paul Hodges (University of Queensland), Jan Hartvigsen (University of Southern Denmark).
Objectives:
Identify the range of different digital health technologies (eg. Webapps, text message) that can support the use of ‘low risk’ and ‘high value’ non-pharmacological interventions for the management of low back pain;
Identify and rank the research priorities in the field;
Discuss where digital technologies can be applied to support ‘right care’ initiatives for the ‘rigth patient’ in their educational, research, or clinical care settings.
Date: Thursday, July 4, 2019 - 1:30 to 3:30 pm
Rationale: Digital strategies can help transform health and ensure the quality and sustainability of high value ‘right care’ for those with low back pain conditions. The use of digitally-enabled low back pain care is intuitive, given the capacity to scale technologies, to deliver system and economic efficiencies, and to mitigate patients’ access and care disparities. However, the current state is a fragmented amalgamation of different technologies being promoted for the care of patients with low back pain without the necessary scientific framework to organize and support them. A likely explanation is the lack of evidence mapping and guiding framework to support clinicians, patients, and researchers in establishing the research priorities in the field to enable the use of technology matched to the right patient at the right time.
Chairs: Rachelle Buchbinder (Monash University and Cabrini Institute), Christopher Maher (The University of Sydney and Institute for Musculoskeletal Health), Jan Hartvigsen (University of Southern Denmark and Nordic Institute of Chiropractic and Clinical Biomechanics), Martin Underwood(University of Warwick), Maurits van Tulder (Vrije Universiteit), Nadine Foster (Keele University).
Objectives: To reach consensus on a plan to develop an internationally-agreed minimal national dataset, that could be universally applied, to monitor status and changes in health care and health outcomes for people with low back pain.
Date: Thursday and Friday, July 4-5, 2019 - 1:30 to 3:30 pm
Rationale: The 2018 Lancet Low Back Pain Series identified a need to reduce the health and economic burden of low back pain and improve its management. To monitor progress, the Series recommended development of an internationally-agreed minimal national dataset, and made broad suggestions for which items to include based upon a survey of the Series Working Group. Building on the GBD study which measures prevalence, disability (years lived with disability) and combined disability and death (disability-adjusted life years) related to low back pain over time, this indicator set could routinely monitor care that is delivered, work disability, health outcomes, cost burden and clinician/societal back pain beliefs. Importantly, uniform data collection would encourage benchmarking of health services within and across countries.
Standardised low back pain definitions for prevalence studies have already been developed and incorporated into the Global Alliance for Musculoskeletal Health Surveillance Taskforce survey module for musculoskeletal conditions. A standardised national minimal dataset module for monitoring progress in reducing the health and economic burden of low back pain could be a valuable addition.
Chairs: Isadora Orlando de Oliveira (Hospital Israelita Albert Einstein), Mário Lenza (Hospital Israelita Albert Einstein), Eliane Antonioli (Hospital Israelita Albert Einstein), Luciana Pereira de Magalhães Machado (Hospital Israelita Albert Einstein), Rodrigo A. Vasconcelos (Instituto Wilson Mello,), Leonardo Oliveira Pena Costa (Universidade Cidade de São Paulo), Mário Ferretti (Universidade Federal de São Paulo).
Objectives: Present and demonstrate the second opinion approach for forum participants; outline patient management and explore evidence-based practice for treatment indication; discuss how the second opinion program could change the dynamics of surgical and rehabilitation processes and also summarize how implementing a second opinion program can contribute for reducing unnecessary care for back pain patients, in clinical and economical perspectives.
Date: Thursday and Friday, July 4-5, 2019 - 1:30 to 3:30 pm
Rationale: Recently, the Lancet series pointed out a challenge in tackling low back pain which is to prevent the use of practices that are harmful for patients while ensuring that evidence-based practices represent good value for money. One way of reducing overtreatment for back pain is to require a second opinion, a multidisciplinary approach that has been used to improve the quality of patients’ care and outcomes in healthcare systems, most likely to be requested when surgery is advised. Multidisciplinary professionals (physical therapists, physicians, nurses, among others), social services, and healthcare institutions work together in a second opinion approach to present less invasive procedures alongside with low-value health care that can decrease the risk of long-term back-related disability.
Chairs: Tamar Pincus (Royal Holloway University of London), Jonathan C Hill (Keele University, Staffordshire), Melanie Noel (University of Calgary).
Objectives:
To familiarise with empirical findings from studies with GPs, physiotherapists, and orthopaedic settings, leading to a development of an effective reassurance model for LBP;
To discuss the added difficulties of reassuring patients in the context of diagnostic uncertainty, including vulnerable groups such as children/youth and their parents;
To discuss the most effective training needs for clinicians in different settings.
Date: Thursday, July 4, 2019 - 1:30 to 3:30 pm
Rationale: The majority of people seeking help for LBP do not receive a precise diagnosis or a clear explanation about the causes of their problem. In the presence of diagnostic uncertainty, it is important to establish a good rapport with the patient, and offer sufficient reassurance to manage worry and catastrophic thoughts. This should result in increased adherence and self-efficacy to manage the problem. Clinicians find it hard to reassure patients with non-specific pain who consult with a desire for a precise diagnosis and a biomedical explanation for their pain. This tricky challenge within the consultation all too often leads to patients being provided with low value care options, such as inappropriate tests and scans. Many clinical services are failing their patients because of a simple lack of good reassurance skills. We will discuss what skills training can be taught to enable our clinical colleagues to more effectively manage patients who are worried, believing that a precise diagnosis is the only way to allay their catastrophic thoughts.
Chairs: Manuela L Ferreira (The University of Sydney), Jill Hayden (Dalhousie University), Paulo H Ferreira (The University of Sydney), Matt Bagg (University of New South Wales), James McAuley (University of New South Wales).
Objectives: Discuss the strengths and limitations of network meta-analyses and present key results in the field of spinal pain.
Date: Thursday, July 4, 2019 - 1:30 to 3:30 pm
Rationale: Most published systematic reviews evaluating interventions for spinal pain use direct pairwise approaches to provide pooled estimates of the comparison between two interventions. This approach fails to provide the comparative effect of multiple interventions – a question most clinicians and patients often ask themselves – which therapeutic approach will provide most pain relief or improvement of function while minimizing side-effects/harms? Network meta-analysis is a design and analytical approach that can be used to compare and rank multiple interventions simultaneously based on the relative effect size for each outcome. This design uses both direct and indirect evidence, making full use of data often excluded from pairwise analyses. Whilst amply used in other related fields, the number of network meta-analyses conducted in spinal pain is still limited.
Chairs: Lise Hestbaek (University of Southern Denmark), Michael Skovdal Rathleff (Aalborg University), Henrik Hein Lauridsen (University of Southern Denmark).
Objectives:
To obtain consensus on which core domains should be used in research into children’s and adolescents’ musculoskeletal complaints
To develop a strategy for future development of measurement instruments to be used worldwide.
Date: Thursday, July 4, 2019 - 1:30 to 3:30 pm
Rationale: Despite the increasing interest in spinal pain in children and adolescents, no instruments measuring pain and disability in relation to musculoskeletal (MSK) pain have been developed and validated in this age group. Consequently, adult questionnaires are frequently applied to children and adolescents without any further psychometric testing. Adults report a broad variety of consequences of MSK pain, including mental and social constraints, as well as physical limitations in everyday life, reduced working ability and various forms of mental, cognitive and social stress. It is unclear whether questionnaires developed for adult populations, can simply be transferred to a younger population. Given the fact that children’s cognitive levels, everyday lives and social relationships are often very different from those of adults, unique domains might be important for children but not for adults and vice versa. In addition, even if outcome domains for adults seem transferrable to children, it is plausible that some specific items may not be suitable in a paediatric context. Over the past decades, research in adult MSK pain, especially spinal pain, has suffered from a plethora of different outcome measures, hampering meta analyses and pooling of data. Research in MSK complaints in children and adolescents is still in its infancy, and lessons should be learned from research in adult spinal pain. Therefore, a set of core outcomes, that are methodologically robust, based on consensus among relevant stakeholders (researchers, healthcare professionals, policy – and decision-makers), and relevant to the age group, should be developed. This could be achieved by creating a ‘Core Outcome Set’, which is defined as “an agreed minimum set of outcomes to be measured and reported in all trials of a particular treatment or condition”. Traditionally, this is developed by integrating evidence from existing literature with the views of relevant stakeholders. However, in this case relevant measurement tools need to be developed and validated as a first step. Over the past two years we have worked with the development of questionnaires to measure the impact of spinal pain and knee pain at the University of Southern Denmark and Aalborg University, respectively, and we would like to use this as a lever to move towards an internationally agreed core outcome set. The routine measurement of the same core set of relevant outcomes will enhance evidence synthesis by enabling comparisons, strengthening evidence syntheses, and facilitating cost-effectiveness analysis.
Chairs: Harbinder Sandhu (University of Warwick), Andrea Furlan (University of Toronto), Sam Eldabe (The James Cook University Hospital).
Objectives: The session will describe the recent Centers for Disease Control and Prevention and Canadian Guidelines on opioid prescribing with a particular emphasis on opioid tapering. The session will provide attendees with information and learnings from the development and delivery of two different approaches to opioid tapering and management developed in two different healthcare contexts as well as research delivery.
Date: Thursday, July 4, 2019 - 1:30 to 3:30 pm
Rationale: The prescribing of opioids for non-cancer pain in the UK has increased by 466% between 2000 and 2010. Yet evidence suggests that opioids are only effective in the short term (up to 12 weeks), after which most patients experience tolerance and some develop opioid induced hyperalgesia. Despite the increasing opioid prescribing problem very little support and advice is available for patients wishing to stop their opioids.
Chairs: Carlo Ammendolia (University of Toronto and Mount Sinai Hospital), André Bussières (McGill University), Christine Comer (University of Leeds), Manuela Ferreira (University of Sydney), Rikke Krüger Jensen (University of Southern Denmark).
Objectives:
Identify innovative and personalized strategies to overcome current barriers that are impeding higher quality research in LSS that can inform practice
Develop comprehensive research priorities in LSS.
Date: Thursday, July 4, 2019 - 1:30 to 3:30 pm
Rationale: Lumbar spinal stenosis (LSS) is a leading cause of pain, disability and loss of independence in older adults. It is usually caused by age-related degenerative changes to the lower spine. Currently, up to 47% of people over age 60 and 9% of the general population are estimated to have LSS. With the aging population, the prevalence of LSS and the associated high economic burden is growing dramatically.
Research in LSS is in its early stages compared to back pain research in general. Published literature reviews on surgical and non-surgical interventions suggest effective treatment for LSS remains unknown. The main reasons given are low quantity, poor quality and conflicting evidence of current studies. Consequently, there are no robust recommendations to guide clinical practice. Sufficient and high quality data on natural history and prognosis are also lacking.
Before addressing the quantity of studies, we must first identify innovative ways to overcome significant barriers to improving the quality of studies in LSS. One obstacle is a lack of a common language defining LSS and its clinical syndromes. The term LSS is an anatomical description yet it is commonly used to describe the associated clinical symptoms despite the large proportion of individuals who have anatomically identified LSS but have no symptoms. Neurogenic claudication, the radicular form and the mixed types of LSS are all different phenotypes each with distinct clinical features and underlying pathophysiology. However, current studies poorly and inconsistently define the phenotype of interest. Strictly defining the population of interest is a fundamental necessity for conducting valid research.
LSS is associated with high levels of hopelessness, depression, fear avoidance behaviour and isolation and these factors likely impact outcomes. Yet very few current intervention studies address these psychosocial factors.
There is also a lack of consistency in outcome measures used to assess effectiveness of interventions. Many patients with LSS do not have low back pain but only lower extremity pain while others have no pain at all, only leg weakness when walking. Therefore, commonly used measures like the ODI and NPS may not be the most appropriate outcome measures in this population. Moreover, few studies measure or appropriately measure walking ability even though walking is the most common impairment in LSS. Objectively measured physical capacity and performance measures or personalized outcomes may be more meaningful.
Chairs: Manuela Ferreira (University of Sydney), Sita Bierma-Zeinstra (Erasmus Medical Center), Paulo Ferreira (University of Sydney), Nadine Foster (Keele University), Jan Hartvigsen (University of Southern Denmark).
Objectives: The objectives of this workshop centers around promoting research and clinical management cross fertilization between the low spinal field and other joint OA fields.
The specific objectives of this workshop are to:
Discuss structural and clinical definitions of spinal OA and its subtypes.
Identify the clinical criteria of spinal OA and its subtypes
Develop a research agenda of top 5 research priorities in the field.
Date: Friday, July 5, 2019 - 1:30 to 3:30 pm
Rationale: Many people with spine pain also have pain in other sites of the body and for some joints this is labelled as osteoarthritis (OA). Clinical and epidemiological features of spine pain are very similar to those of for example OA in the knee, i.e. risk factors, course, prognosis and clinical management. Nonetheless, OA in peripheral joints have structural and clinical definitions whereas pain in the spine is often labelled as “nonspecific” resulting in researchers, clinicians, and healthcare administrators thinking about pain and disability in the spine as something different from pain and disability in peripheral joints. Furthermore, associations between imaging and pain are similar between the spine and peripheral joints, i.e. degenerative changes on imaging do not necessarily equal pain and decreased function. Finally, guidelines across pain sites are strikingly similar in recommendations for the management with a strong focus on non-pharmacological interventions such as patient education and exercise. Because of these similarities, researchers and clinicians are increasingly interested in researching and managing musculoskeletal conditions across pain sites and diagnoses. These efforts are however hampered due to lack of standardization of terminology and definitions for apparently similar conditions. It is therefore timely to discuss whether OA also occurs in the spine and how it should be defined.
Chairs: Bart W. Koes (University Medical Center, University of Southern Denmark), Alessandro Chiarotto (University Medical Center, Vrije Universiteit), Martin Underwood (University of Warwick), Shilpa Patel (University of Warwick), Jill A. Hayden (Dalhousie University), Maurits W. van Tulder (Vrije Universiteit, Aarhus University Hospital).
Objectives: The main objective is to explore the feasibility and to establish boundaries of a database of RCTs for LBP.
Date: Friday, July 5, 2019 - 1:30 to 3:30 pm
Rationale: Based on small to moderate effect sizes of the wide range of interventions for low back pain (LBP), and on the clinical heterogeneity of LBP patients, there is a strong need to explore subgroup effects and to identify mechanisms of action of different interventions. Meta-analysis using individual patient data (IPD) from randomized controlled trials (RCTs) is considered the best available method to investigate subgroup effects and causal mediators of interventions. Building a database of RCTs for LBP from all over the world would greatly facilitate IPD meta-analysis. The organizers of this workshop wish to establish an international collaboration to initiate such database (or trial bank).
Understand how innovations in clinical data collection can transform integration of complex pain information at the point-of-care to deliver personalized pain medicine.
Explain how a new multi-modal assessment framework can integrate the patients’ personal pain experience within research and clinical practice.
Describe how complex intervention development can be applied to design a personalized treatment for acute low back pain in primary care.
Date: Friday, July 5, 2019 - 1:30 to 3:30 pm
Rationale: Although it is known that pain is a complex, multidimensional experience, pain management pain often occurs within a biomedical framework. Because of this, treatments for people with complex conditions such as back or neck pain are not adequately personalized to address the unique mosaic of biological, psychological and social factors that integrate to create each person’s pain experience. Overcoming this problem requires tools for clinicians to identify and address the complex multidimensional drivers of pain. Delivered by three inter-professional leaders in clinical pain research, this workshop will reveal innovative approaches to better understand the complexity of spinal pain to deliver personalized treatments that improve clinical outcomes. First, Beth Darnall will explain how the NIH-funded online platform known as CHOIR (Collaborative Health Outcomes Information Registry) integrates clinical data from patients seen in pain clinics every day, and can help clinicians design personalized treatments, and track progress. Second, Timothy Wideman will describe a novel framework for understanding the subjective personal experience of back and neck pain (Multi-modal Assessment Model of Pain). Finally, Julia Hush will describe new work on how complex intervention development has been used to design personalized treatments for acute low back pain in primary care.
Chairs: Tasha Stanton (The University of South Australia), Ann Meulders (KU Leuven & Maastricht University), Felicity Braithwaite (Flinders University & The University of South Australia).
Objectives: To bridge the gap between experimental science and clinical trials by increasing knowledge of how experimental science may aid clinical trial planning and execution.
Date: Friday, July 5, 2019 - 1:30 to 3:30 pm
Rationale: Despite significant attempts to bridge the gap between experimental findings and clinical application, there is both significant delay in translating experimental results to clinical trials as well as significant failure. One key reason behind such failure is the disconnect that often occurs between experimental scientists and clinical trialists – how can experimental findings be feasibly used in clinical trials? This workshop will aim to discuss and explore practical strategies to integrate experimental findings within the clinical trial setting. Specifically, this workshop will discuss the use of mediation analyses of experimental outcomes to test causal inference to promote and inform mechanistic targeting in clinical trials. First, the experimental outcome measures used for pain-related fear avoidance and generalisation will be discussed, with a focus on how these may be embedded within clinical trial designs (Dr Ann Meulders). Second, the workshop will discuss the impact of response bias on clinical trial outcomes and thus the relevance of using both explicit (self-report) and implicit (experimental measures that measure bias) outcomes to assess the effects of treatment and how these can be used within mediation analyses (Associate Prof Tasha Stanton). Last, this workshop will also discuss the use of innovative placebo interventions that can maximise both clinician and patient blinding with a focus on how existing placebo interventions can be enhanced/refined using experimental evidence (Dr Felicity Braithwaite).
Chair: Lianne Wood (Keele University), Nadine Foster (Keele University), Jill A. Hayden (Dalhousie University), Gert Bronfort (University of Minnesota).
Objectives: To gain an international consensus on the key treatment targets for RCTs of exercise interventions in LBP, identified from previous research (systematic review and a UK-based workshop).
Date: Friday, July 5, 2019 - 1:30 to 3:30 pm
Rationale: Exercise is the most widely recommended intervention for low back pain (LBP), based on more than 200 randomised controlled trials (RCTs), yet we are still unclear about the treatment targets of exercise. This uncertainty was confirmed by our recent systematic review of exercise RCTs for LBP that identified 30 different treatment targets. Exercise is a complex intervention, characterised by numerous interacting components, and variation in dose, duration, setting and personalisation (Ferreira et al. 2010). Despite this, the effectiveness of exercise for LBP in RCTs is most often judged by a single or ‘primary’ outcome measure (usually pain or function). Future RCTs of exercise cannot include measures of 30 potential exercise targets, rather what is needed is a consensus about the most important treatment targets that can be measured consistently, as either mediators or outcomes (Chiarotto et al. 2014; Harman et al. 2013; MacLennan et al. 2015). This workshop will use a nominal group technique (NGT) to gain consensus on the most important treatment targets of exercise for LBP. NGT allows each person an equal opportunity to share their ideas, discuss them and then to rank suggestions and gain consensus. (Waggoner et al. 2016). Gaining consensus about the treatment targets of exercise and encouraging consideration of targets in planning research will i) ensure that future exercise interventions are more clearly described and specified, ii) facilitate RCTs to capture more consistent data about the targets of their exercise intervention and iii) potentially change the conclusions of RCTs testing exercise interventions if the primary outcome is targeted to the treatment targets of the intervention.
