Engaging consumers living in remote areas of Western Australia in the self-management of back pain: a prospective cohort study

Persistent low back pain (LBP) is poorly managed and consequently the associated health and economic burden for consumers and for society are substantial [1, 2]. For consumers with persistent pain (of which in Australia, LBP represents a significant proportion of the musculoskeletal contribution [1]), less than 10 per cent of patients gain access to effective management, yet according to recent international data, up to 80 per cent could feasibly receive effective care [2, 3]. Furthermore, reliable data indicate that the burden of persistent pain for consumers and society can be markedly reduced when available evidence-based management is implemented [2, 4].

Many factors contribute to this gap in healthcare for consumers with LBP, including the failure of evidence to be translated into best practice [5–7], an inadequately trained and skilled health workforce [8, 9] and a lack of co-ordinated interdisciplinary care [10], the latter being a favoured model for consumers with persistent LBP [11]. To obtain effective care is difficult because persistent pain is often poorly understood by the general community, by educators, researchers and health professionals [3, 12], often resulting in stigmatization and conditions not being legitimized [13, 14]. While there is overwhelming neurobiological evidence of changes in the brain which typically underlie persistent pain [15–18], many health professionals still view consumers with persistent pain within a framework that is biomedical rather than biopsychosocial [19], thereby missing the importance of taking a whole person approach to pain management.

Additional disadvantage exists for consumers with persistent LBP who reside in geographically isolated regions, where there is even less access to evidence-based pain services and community support [12, 20]. This is the case for many Australians, where a large landmass is populated with low densities of people, dispersed outside of urban centres, particularly in Western Australia (WA). In this study, we targeted three remote WA locations, which included Kununurra, Albany and Kalgoorlie. Taking the shortest travel route, these towns are situated 3206 kms, 595 kms, and 409 kms respectively away from the state capital Perth. Kalgoorlie and Kununurra lie in the most sparsely populated areas in the state, having a population density of less than 0.1 persons per sq km [21]. Developing innovative models of service delivery based on a contemporary perspective of persistent pain and aligning these models with a skilled workforce, is one strategy targeting the needs of people in these remote areas [22]. Integral to such a model of care for the management of persistent LBP is the facilitation of consumer use of active self-management strategies [23–25], as these are associated with significantly lower rates of health care utilization compared to solely using passive options [23, 26].

The focus in this study was the implementation of an interdisciplinary model of care for consumers with LBP living in remote areas of WA using a previously established and consumer-oriented Self Training Educative Pain Sessions (STEPS) program [25]. In a tertiary setting, STEPS has demonstrated significantly reduced wait-times, costs per new patient episode and volume of outpatient appointments and in parallel, an increased utilization of active pain management strategies and increased patient satisfaction [25]. The aim of this project was to deliver and evaluate the effectiveness of a modified STEPS program (mSTEPS) to consumers with persistent LBP living in geographically isolated areas of WA.

This study evaluated the outcomes of delivering a consumer-oriented, evidence-based interdisciplinary pain education intervention, mSTEPS, to consumers with persistent LBP residing in three geographically-remote areas in WA. At baseline, consumers demonstrated scores suggesting positive back pain beliefs, adequate health literacy and positive health behaviours, the latter reflected by the use of more active than passive strategies in self-managing their persistent LBP. Immediately following mSTEPS, consumers’ general beliefs about back pain were significantly more positive indicating a short term improvement in beliefs and the vast majority of consumers rated the program as useful. At 3 months post-mSTEPS intervention, there was no evidence for significant improvement in any baseline measure. This lack of longer term effect may reflect the already high baseline measures or could indicate that additional reinforcement strategies are required in order to sustain improvements in back pain beliefs. Whether a sustained improvement in back beliefs facilitates the adoption of more positive health behaviour is unclear, although it is likely that additional reinforcement strategies are required for this to occur.

In our study, general back pain-related attitudes and beliefs were similar to those reported in other Australian populations with and without LBP [43, 48, 49] and to other international cohorts [50]. Immediately following mSTEPS, the clinically significant shift towards more positive beliefs about back pain and its consequences was an important outcome, given negative attitudes and beliefs in consumers with persistent LBP can significantly contribute to disability [39, 48, 51, 52]. The magnitude of the positive shift was similar to that previously demonstrated following an Australian population-based intervention designed to improve beliefs about back pain [51, 53]. However, the positive shift in the same-day beliefs in the present study was not sustained when examining differences in 3 month-responder scores at baseline (27.2 ± 6.9), same-day (30.3 ± 7.0) and at 3 months post-intervention (28.4 ± 6.8). These consumers demonstrated a significant decrease in scores at 3 months from their significantly improved levels immediately post-course. The pattern of decrease in BBQ scores is unclear, as data were not collected between the same-day post and the 3 month test points. Therefore, we can safely surmise that a brief intervention such as mSTEPS, used as a stand-alone intervention, appears insufficient to generate a sustained improvement in back beliefs and it is likely that additional measures are required to achieve a sustained positive shift in consumer back pain beliefs. Support measures may involve the repetition of simple evidence-based messages using multimedia [53, 54]; supplemental educational written materials [50]; reinforcing strategies delivered via internet-based educational approaches [55]; or active management and group-based cognitive-behavioural approaches [56, 57]. The use of internet approaches may be particularly well-suited to geographically-isolated consumers with LBP. Furthermore, we suggest that regular community-based group sessions for consumers with LBP with limited access to pain services and community support [12, 20], should be considered by health funding bodies, given the available data demonstrating their cost effectiveness and positive health outcomes [57]. Collectively, our findings suggest that it is important to use any transient change in beliefs as a potential ‘therapeutic window’ to encourage the adoption of positive behavioural change, as beliefs and behaviour for consumers with persistent LBP do not necessarily match [43].

In our study cohort, pain catastrophizing scores were lower compared with those previously reported for people with persistent LBP [58], but higher than those reported for a younger WA urban population with persistent LBP and high disability [43]. Half of the consumers in the present study had elevated fear avoidance beliefs scores, similar to those reported in other LBP populations [59, 60]. The need for these cognitive and emotional factors to be addressed is highlighted given that catastrophizing and elevated fear avoidance beliefs can interfere with the adoption of beneficial health behaviours [61]. In this context, the use of timely cognitive-behavioural group sessions, which appear to provide reassurance, lessen isolation and enable participants to learn strategies from each other and re-engage earlier into the workforce [57], could align well with the delivery of a community-based LBP management program. The manner in which messages are conveyed to consumers by health professionals should also be considered as our data highlight a proportion of consumers have some level of difficulty understanding health information and communicating with health professionals, while other evidence points to poor quality communication strategies adopted by health professionals in the context of LBP, particularly with consumers who experience persistent LBP [62].

For treatment of their LBP, consumers accessed primarily general practitioners and physiotherapists or chiropractors, possibly reflecting the available services and accessibility. Notably, almost half of the cohort had also consulted a specialist regarding their persistent LBP, and on most occasions, this would have required them to visit a tertiary facility in Perth. The provision of additional services to assist in reinforcing key health messages and to encourage positive health behaviour could be achieved, in part through community-based educational programs combined delivered by ‘virtual’ interdisciplinary teams using novel information technologies, or by the provision of reliable, accessible and evidence-based information resources at the community level, a need previously highlighted by consumers [27]. Such innovative solutions could potentially improve health system efficiencies by providing opportunities to simultaneously upskill both health care professionals and consumers and reduce the need for these consumers to travel to tertiary centres, thereby supporting contemporary health policy directions.

An additional and important component of any optimal model of care for the management of persistent LBP is the facilitation of consumer use of active cognitive and behavioural self-management strategies [23–25]. At baseline, consumers used more active cognitive-behavioural self management strategies than an urban WA population of consumers with persistent spinal pain [25] and more active than passive strategies. Using active strategies to assist in self-managing persistent LBP is important as such approaches substantially reduce the likelihood of consumers having high levels of pain-related disability [23]. Furthermore, adherence to specific self-management strategies can predict reductions in pain, disability and depressive symptoms even after controlling for the moderating effects of catastrophizing, fear-avoidance and pain self-efficacy beliefs [63]. In our study, consumers most frequently employed simple active behavioural approaches that aligned well with their functional limitations, however associated qualitative data from a subset of these consumers suggests that assistance may be required with the adoption and maintenance of long term self management strategies [27]. This may be particularly true for those consumers (up to 71%) reporting difficulty with the broader elements of health literacy, potentially reducing their capacity to engage in positive lifestyle behaviours [27].

Active self management behaviours did not increase significantly at 3 months, although at baseline use of these strategies was already quite high. Several factors which impinge and encourage uptake of self-management strategies have been identified [23, 64], and require consideration in the context of our cohort. These can be summarized as follows: 1) limited resources and access to resources; 2) ineffectiveness of pain-relief strategies (evident by those passive conventional strategies chosen by consumers as not helping to relieve their LBP and which included surgery, operations, physiotherapy, chiropractic, acupuncture and medication); 3) time constraints and other life priorities ([27, 43]; 4) avoiding activity because of fear of pain exacerbation; 5) a lack of tailoring strategies to meet personal needs (possibly incorporating the lack of coordinated interdisciplinary care or limited access to such services); 6) not being able to maintain the use of strategies after the mSTEPS intervention; 7) physical limitations (reflected in consumers’ functional limitations); 8) sub-optimal patient-physician interactions; 9) difficulty in the broader aspects of health literacy.

Standardized evidence-based approaches to chronic health conditions with flexible and tailored self-management and personalized co-care plans could better match consumer needs to resources [65, 66], although readiness for change [67] and adherence to these evidence-based approaches is important in optimizing patient outcomes [68, 69]. To encourage appropriate service delivery and facilitate the uptake of active self-management and co-care for consumers with persistent spinal pain, we recommend that policy makers and health professionals address the following key considerations: 1) timely provision of integrated evidence-based interdisciplinary co-care [70, 71]; 2) ensuring the availability of supportive health professionals [72] and carers; 3) providing a menu of different self-management strategies allowing better matching of consumer profiles with appropriate resources to optimize health outcomes [66, 73]; 4) facilitating adherence to self management [63] and providing reinforcement to help encourage the adoption of positive behavioural change [64, 74] with reference to an operationalized stages of change framework [75] and readiness to adopt self management [67]. To address these changes requires system plasticity at the individual level (preferably using a who le p erson e ngagement model, which we term the HOPE model), in primary care (appropriately skilled interdisciplinary workforce), at a community level (community-based training programs), and at a tertiary level (integrated interdisciplinary co-care). The novel use of information technologies may facilitate such system plasticity for the benefit of health consumers living in geographically-isolated areas.

Our study has several limitations and the applicability of these findings to other populations of consumers with persistent LBP may be limited because of the following factors: a randomized controlled trial would strengthen the study design, as currently the lack of a control group precludes a comparison of the natural time course of outcome measures with change specifically attributed to mSTEPS; data were based on self-report measures; a modest sample size (therefore we cannot control reliably for potential confounding factors like socio-economic status, high and low disability); responder bias (response rate of 49%); and selection bias (consumers in this study were predominantly female (68.8%) and educated (62% had completed high school)). Additionally, consumers were self-referred to mSTEPS and their motivations for attending this educational intervention may differentiate them from consumers not seeking care for persistent LBP.

The implementation of health policy through a consumer-oriented intervention, set within a contemporary pain management evidence-based framework, can be successfully delivered within primary care. In order to focus management on the whole person and to encourage positive consumer health behaviour, appropriate post-intervention support systems, including access to health services and to appropriately skilled workforce, are recommended. Our findings highlight the need for health delivery change if the current best research in spinal pain is to be effectively and sustainability translated from policy into practice for consumers with persistent LBP living in remote areas.

HS is a clinical researcher and a Specialist Musculoskeletal Physiotherapist with Honorary position at Fremantle Hospital, Pain Medicine Unit. AB is a senior researcher supported by a Fellowship from the Australian National Health and Medical Research Council (NHMRC). SD is a Pain a Medicine Specialist and Head of the Fremantle Hospital, Pain Medicine Unit and Director is Statewide (WA) Pain Medicine Services. AS is a senior researcher and biostatistician who is supported by a Fellowship from Curtin University. JQ is a Rheumatologist and Pain Medicine Specialist. SB is a doctoral student and research assistant.

The following authors received honoraria for delivering the mSTEPS programs: SD and JQ.