Back pain, imaging and overdiagnosis

 Back pain, imaging and overdiagnosis

Millions of dollars in Australia is spent on back pain imaging per year. But there are many common misconceptions with spinal imagery that often lead to overdiagnosis. So what is overdiagnosis? It's the diagnosis of a medical condition that would never have caused any symptoms or problems that can lead to psychobehavioural apprehension, worry and change in behaviour. Welcome to Talking Physio, an initiative of the Physiotherapy Research Foundation. The foundation supports the profession in a number of ways, including the promotion and translation of research. This episode is proudly sponsored by Flexeze, Australia's number one heat wrap. It's been clinically proven to be effective for back pain relief lasting up to 15 hours. Flexeze is the exclusive partner of the Physiotherapy Research Foundation. In this episode, physiotherapists Dr Adrian Tragaer, Postdoctoral Research Fellow University of Sydney, Associate Professor Tasha Stanton, University of South Australia and Dr Emma Karran, Postdoctoral Research Fellow, University of South Australia; they discuss why overdiagnosis is a huge problem and why it impacts our critical and our health systems. The trio stress the importance of patient communication strategies, the need for public health strategies to increase awareness and high value care such as exercise, which can help regardless of the severity of the condition depicted on a scan. This episode is super interesting and a must listen for anyone working in allied health.

So I feel really excited actually to talk with you guys about this because I think in Australia you guys are doing some of the most exciting work in this area and the fact that it's actually becoming a topic, I think is super important. And so I'd be really interested Adrian, to hear a little bit more about what's actually happening at the moment in Australia about overdiagnosis. I mean, you're working with a really strong group at the University of Sydney that are at the forefront of this. Could you introduce this to us a little?

Yeah, sure. So the collaboration that I'm working in at the moment is called the Wiser Healthcare Collaboration. And this is a research collaboration that's been funded by the Australian government to work on this issue, because the government's recognised that overdiagnosis is a big issue. So it's brought together three different universities, major experts in the field, including Paul Glazier at Bond University, Rachelle Buchbinder at Monash, Kirsten McCaffrey at Sydney Uni, who's a psychologist and Professor, and Chris Maher at Sydney Uni. So that's the group that I work within and we're really trying to understand this problem of overdiagnosis and develop some solutions. And there's really interesting overlap, I think, between the work we're doing to communicate about overdiagnosis and the sort of work that Emma's been doing to discuss imaging with patients and those sorts things. So I think there's really interesting intersections between the work that we're all doing on this, and it's a huge problem. You know, the reason that it was funded by the government is because they thought that this is something that has potential to challenge the sustainability of our health system. So if we provide too many tests and too many treatments for an ageing population, then the health system is going to collapse and people aren't going to get better. So it's, it's a critical thing to understand, and it's a critical thing for us to develop solutions for.

So do we have a sense of how much overdiagnosis costs Australia?

Yeah, that's an interesting question because overdiagnosis can happen in all different body regions and in different fields. So the famous examples are from cancer and cardiovascular disease. But we're starting to see issues emerging in musculoskeletal, which is obviously where I work. And to just take one example, so imaging for musculoskeletal pain or imaging for low back pain, which we know it's not indicated for most people who have back pain. Australian public money there's about 300 million spent on imaging tests for back pain of public money, and that's a huge amount of money every year. 300 million every year on a test that may not bring any benefit to patients, could potentially harm them, and that's money that could be spent on all these things we could be doing as physios that we know are evidence based.

So I guess I suppose the want to ask for some of these tests is clearly driven by probably beliefs that they will help. I don't know, Emma, some of your work might be relevant here. What are the common misconceptions that we, or the myths in this area that we think occur for patients that are going in and trying to figure out, ‘What's wrong with me?’

There's quite a number of myths that are associated with low back pain and around the need for spinal imaging and also what spinal imaging actually tells us about what's wrong and what's not wrong with their spine. So my research is interested in the consequences I suppose, of this overdiagnosis and over imaging that is really prevalent in the society today. Certainly there's misconceptions around the need for a scan when someone has an episode of low back pain. It's certainly a really common scenario where a person will go to their doctor really expecting that they will get a scan, believing that it's important for guiding the future care of their lower back, or just important to get that diagnostic label. And we're understanding more and more these days about the potential harms in that sort of approach and the need to change practices to avoid some of those harms. Patients may, or may not be, aware of the harms related to exposure from the scans that they get, but that's also related to what their scans actually show, and the interpretations that they make of those scans. So we can call these sort of psychobehavioural harms and that's a word that really describes how people change what they believe and what they think about their back when they have a scan. Radiologists are really obliged to report all sorts of, everything they see when they review a scan. And many of these things we know now, just simple things like disc bulges, facet joint degenerations, stenosis, a lot of phrases which people interpret as really quite scary in many cases can have harmful impacts because they cause people to be really apprehensive. They can cause quite significant degrees of worry and also cause people to change their behaviour so they might be less likely to be active, which is going to have longer term impacts on their function and lead to greater disability. So there's a lot of things, consequences, of scanning that perhaps are poorly understood in the population.

Yeah, that's so interesting to think in the context of back pain and some of the work that I do. I work mainly in osteoarthritis. It's interesting because scans are often used to provide a diagnostic label in osteoarthritis. To say, ‘Yeah, you've got osteoarthritis of the joint’. But then it gets really challenging because certainly there might be some value in doing that and diagnosing that, because maybe they can get more access to different services. The trouble is it seems from some of the qualitative literature that people with osteoarthritis, they don't have a really good sense of what that information tells them. So there's this idea that what they see there actually determines their future. So if it looks really bad, I should expect that I should have this level of pain. It's never really going to change because those scan findings don't change. And that's a really big misconception. And I think, as you mentioned, it has that similar link. It then makes it difficult to think that you should be doing exercise or doing other things because you've got this terrible degenerative joint. And I guess it is interesting because there is that immediate sense, and I guess belief, that what they see on the scan is what's causing their pain. And I guess from a global, larger pain science background, that's not the case necessarily. And so we are in this situation where sometimes seeing this stuff might be helpful in them feeling that they know why they're knee hurts. For example, ‘I've got osteoarthritis’. But when we have these preconceptions that what I see here determines what I can do, rather than it showing me a picture of the joint at this moment, I think that really has implications and those myths are really pervasive. So we see that a lot in older adults that go in and have scans, is it almost feels that their future's determined once they see that.

Yeah it's a real challenge, with the effect these reports can have on people's behaviours and you can get these really contrasting reactions to diagnostic imaging findings. In one sense, someone might be really relieved that there is pathology on there because it's sort of legitimises their pain. So in qualitative research that we've done, we've just finished a big review on people's beliefs about imaging findings, and in one sense it can reinforce that this scan is the cause of my pain. But some patients like that. Some patients like to have evidence. But what they don't understand is that that's not really very good evidence that that's the cause of their pain. But they could have these paradoxical reactions. Some people are more scared by seeing the scans. Some people are less scared. So it's really unpredictable what will happen.

And I think we are in a situation where clinicians themselves may not be fully informed at all times about the need for imaging and these potential negative consequences that can come from it. And we also know that GPs, for example, often believe that their patients expect that they will get an image when they present for care. But there has been some more qualitative research that's shown that that that's not always the case. I actually undertook an online study where we recruited over 600 adults to complete an online questionnaire. These were adults with or without low back pain. We got them to put themselves in a scenario where they had injured their back, they'd presented to healthcare, and then they were randomised to groups where they either received a scan or they didn't receive a scan. And those groups who didn't receive a scan were given some high quality information in line with best practice care. And what we found was that those who didn't receive the scan were actually more reassured than the patients who did receive the scan. Provided that is of course, they did receive good quality information, which may not always happen adequately in primary care. And that's perhaps another challenge that you'll be able to talk about, Adrian.

Yeah, that's really interesting to consider in terms of when they're getting this high quality care. I guess that links in really lovely with some of the osteoarthritis stuff where we look at qualitative work, is because when clinicians are sometimes interpreting these scans for patients, that doesn't seem to always be high quality care. In the sense that, oftentimes they're using terms like wear and tear, which immediately gives this clinical reinforcement of, "You know what, you've worn out your joint so therefore, if you do more activity, more tear, you're going to wear it out further." So it has this implicit and sometimes explicit message that actually you can make this worse. And even this then links into, I think, sometimes clinician behaviour. So if they see this terrible scan and they have this belief that what they see, let's say, on a very degenerative knee X-ray, is completely dependent or predicting people's pain and their response to treatment, they may hold beliefs that actually exercise isn't valuable for people that have severe degenerative changes. When actually really high quality level evidence from systematic reviews shows that there can be improvement even when people have really late stage osteoarthritis. Exercise can still help. And I guess it's always interesting to consider who the pain patients are seeing. If they're seeing general practitioners first or physiotherapists. Because certainly there's some evidence to suggest that when patients have gone in with osteoarthritis to see a GP, sometimes the GP will look at the scan, but really kind of put it off and just say, this is a normal process of ageing. You should expect this because you're getting old. But not in the way that it's saying, this can happen, these changes might be normal and don't mean that you necessarily have pain, but rather you should just accept this, your body is starting to break down. And this was a real thing that came out that patients just felt, I guess, a dissonance with GPs. With not necessarily, I guess, feeling reassured by what they were told, but also feeling like their condition was being downplayed as something that it doesn't matter because you're old. And I think that's not a lovely place to be in, but really important information to know how we might shape encounters.

It's a fine line to tread. It's a really fine line between dismissing what's on those scan results and validating someone's pain and experience. And I think we're still thinking through the best way to do that, you know, that won't invalidate someone's experience, but won't actually increase worry or send them down a path of treatment that may not lead to the best outcomes. But it's a tricky one, you know. It's a fine line to tread.

And do we run into a problem? The aim of some of the stuff that you're working on the moment is increasing awareness of overuse of imaging. Do we run into a problem where we can go too far the other way?

Yeah, look I think we can. I think that we should always keep in the back of our mind the importance of timely diagnosis for musculoskeletal pain. So for back pain we have, where people would be well aware, we have catastrophic things that we must pick up as frontline practitioners. And so there's a balance there as well between, you know, if we're trying to discourage overuse of imaging, we want to make sure we're not discouraging use of imaging in general. It's just use of imaging when it's not indicated, which is tough to do because we're looking at public health strategies and these sorts of things which are giving quick messages to the public. And it's hard to get the nuance there about red flags. And so without actually having to do really in depth clinician training about indications for imaging, like you brought up Emma, I think that's a key aspect to addressing this problem: clinician training. And we need to change curricular around Australia and do those big things. But it is a tough one to communicate to the public, because we don't want to scare people off having a scan in the rare event that they have got cord compromise or something, that they really do need that urgent MRI. So that is something that we're thinking through in the research we're doing in the communication strategies that we're doing to, you know, not give the message that imaging is bad in general. But, you know, try and get that message that overdoing it is not helpful and that there are some harms. It's not that there's no harm just having the scan. There are some harms that are well documented that people just don't seem to be aware of. So we need to raise awareness of those harms but not discourage imaging altogether.

And when they do have imaging, you mentioned the challenges of that clinical consultation. So what should we be saying to the patients who are in front of us that will validate their pain complaint, that will validate findings, that are often very relevant that are found on imaging. But then try to de-threaten all those findings that are probably found incidentally and have no relationship to their pain complaint. They're probably likely to have pre-existed their pain and they're likely to be there forever and really be of no consequence. And how do we get patients to really understand that?

That's where GLITtER came in wasn't it?

That's a beautiful study. You know, at that stage of the consultation when someone comes to you with imaging, having a new way of communicating that to the patient.

Yeah, that's right. So GLITtER was a study. GLITter is an acronym for Green Light Imaging Interpretation to Enhance Recovery.

GLITtER's lots easier! But that was a consultation, it was a framework for a clinical intervention that we developed that was really quite specific for use in the Spinal Assessment Clinic, where we've got patients who routinely came in with spinal imaging findings. And these were spinal imaging findings that often you could see had led to quite significant and fixed beliefs about pathology in the patients who were presenting for care. So we decided to develop really just a framework to sort of standardise and optimise the information that we were giving to patients. It was designed to be delivered in 10 or 15 minutes as part of the general clinical interaction involving an assessment. Full assessment and full explanation of what the relevant findings were on the imaging, but also took a unique approach of using the images as a clinical tool to reassure patients. So rather than just pointing out everything that was wrong with the spine, pointing out the aspects of the spine that offer structural integrity and strength and stability, and convey the idea that the spine is a structure that needs to move to be healthy and perhaps isn't the vulnerable structure that they believed had needed protection.

So this is training that you did with the clinicians, so you upskilled the clinicians in this approach?

Yeah, in this setting I guess the clinicians probably didn't need to be upskilled a lot because they were consultations that they were used to taking part in. So it was really a framework, I suppose, just to make sure that it became standardised, that it routinely was optimally delivered, high value care. And it was care that was also supplemented by a few novel aspects of GLITtER I suppose, in that we developed some posters. A 4 week series of posters which patients were able to put up on their fridge that really reiterated a lot of what we'd talked about in the clinical consultation. It gave links to online resources that were high quality that could supplement the information that they were given. We sent them an SMS once a week, just to prompt them to read through and to turn their poster on to the next page. And we also communicated with their GPs about the sort of messages; well about the understanding from the expert clinical consultation of what was going on and what the scans meant and what the best pathway towards recovery was going to be. It was really important, we thought, to be able to communicate that to the GP so that there was a consistency of messaging from health care providers delivered to the patient as much as possible.

Because you guys have been exploring different communication materials as well, haven't you Adrian?

Yeah, it's more in that stage before someone's had imaging. So that's the nice link between mine and Emma's work. Mine has been a little more focused on when people present to either primary care or the emergency department with back pain and some strategies at that point to try and raise awareness of the potential harms for imaging. But it's a tough one because emergency settings, I don't know if any of you have been in emergency room recently, they're pretty busy, crazy places. Back pain is low on the priority list of doctors. Their priority is just to not miss anything nasty. And yet it's an increasingly frequent place for people to present to the emergency department for simple back pain. So we thought it was a good setting to raise some awareness. People are sitting in the waiting room there, sometimes for hours, with back pain. To print some materials and get some increase access of patients and the public to materials that can explain the issues related to overdiagnosis. Again, it's a challenging one because even the qualitative work we've been doing on the materials that focus on the harms of imaging, people can have quite a negative reaction and think it's more a cost cutting exercise for the government. And actually, they don't believe that there are these harms related to imaging and so it's hard to persuade them that imaging is just not a routine test anymore.

Yeah so especially in the emergency department, you're at this heightened level of anxiety and stress, and it's a hard place to take in information. But I think that's a really, really innovative way. Maybe we could make it multi-sensory. Can we like, give them some headphones and give them some nice Bach? And then they could read into... There we go, next project grant!

I think that's great for the emergency department. Yeah, sound reducing headphones would be just right. Yeah block at the screams!

Because it's so cool to hear some of the pioneering stuff that you guys are doing in back pain because in comparison, we're really at early stages with osteoarthritis. There's not as many materials or things developed. So at the moment we're leading a study that's looking at developing general pain education tools and strategies for people with osteoarthritis. And an important part of that is how we frame and how we talk about imaging. And I think some of that we've really delved into the literature to look to see examples, I guess, that it kind of gives them some challenging things to maybe what beliefs people might have about that. So an example being quite a recent study showed that if you take asymptomatic people and you put them into a MRI scanner, over the age of 40 about 43% of them will actually have MRI evidence of osteoarthritis; but they have no pain. So sometimes I think that information doesn't get out there to people and it can give them this alternate idea of what's going on, an understanding of what's going on. And then if we can supplement that with understanding of the complexity of pain and that actually that's a good thing, because it means we have all these other targets that we didn't even know about. But I think that could be quite powerful. So yes, I was keeping a keen eye on all you guy's work to be like, what can I poach?

Well that is a nice aspect of pain education because I have a bit of background in pain education, as you know, when we worked in Body in Mind. And I think one of the really nice aspects of pain education that we can tap into is, it has a gentle way of addressing some of these tough beliefs. I've moved a little bit away from that in the strategies we're using now, and they're quite punchy, public health strategies. They're almost on the negative way of, almost like a fear campaign, which I'm a little bit uncomfortable with, but behavioural experts would suggest that this is one of the ways that you can change people's behaviour. But what we're finding is that when you take that approach and try and address people's beliefs, for example, the imaging test shows pain and you try and just simply say, ‘Imaging tests don't show pain.’ Even that message on its own, it's so important. And yet the public that we've been testing it on tend to react really negatively to that message. Whereas a little more nuanced and the pain education approach, does give that more positive message and an alternative rather than just telling people, ‘That's not the cause of your pain’. There's the follow up, and there's the explanation for, ‘What is the cause of my pain, if that's not it?’ But it's a tough one to get across in public health strategy. So you guys, I know you're doing the pain revolution, and this is one of the big focuses of that, but I'm still trying to reconcile those things in quick public health messaging with pain education strategies that really do need a bit more time and individualisation in some cases. Otherwise you're going to get a very angry person.

Yeah, and I completely agree with that. I understand that because I think even personally, if you've had an experience that something's hurt forever. Like it's been bothering you for ages and you go in you're like, I want to know what's wrong. I want to figure out what's wrong. And like man, I had the most embarrassing thing in the whole world. I have foot pain on and off, and I've had this forever. And they – UniSA - had a study a while back. A peel pain study. So I signed up, and as part of that they did an ultrasound of people's feet - the participants. And so while I was getting it done, I happened to glance over and I was absolutely shocked. I saw I had basically a partial thickness tear of my planter fascia. And I was like, ‘Oh my God, I didn't actually think anything was wrong. Oh no!’ But then I was part of the study and they gave us new running shoes and you had to go run. So the first day that I went to go run, like I reckon I made it 400 metres before I just had stabbing foot pain. So I obviously attributed it to the new shoes. So I went and tried the old shoes and I maybe made it 500 metres and my foot was so sore. And then by that point, I kind of sorted out that the only thing that had changed between the week before where I could run about 10 kilometres, and the next week, was that I had seen this terrible looking ultrasound. And so I called the study coordinator, and I just said, ‘I'm so embarrassed. I'm a little bit of a head case, can I please come up and look at this ultrasound image again? It really freaked me out. I just need to make peace with it’. And so he agreed, laughed at me a little bit, but took me back upstairs and he showed up the ultrasound image on the screen, and I was just aghast. It was totally fine. He’d showed me that the wrong image was up on the screen that I looked at. It wasn't even mine. And so then you know, of course, the next day I go for a run and I'm fine. So it was so embarrassing because I should know better, right? I work in pain science. But I think we really underestimate the visual potency of seeing damage and the way that I think our brain uses information about that to determine what's going on in the situation? Do I need to be protected? So I guess I always knew it was important, but I was very much humbled at how important it was for me. And I don't know, getting that message across to people is really hard. I suppose one of the things that we have found a bit interesting is finding physiotherapists and different clinicians that are really interested in getting really good at that. So do you guys have opportunities for different physiotherapists or other clinicians to get involved with processes like this? So I think Emma you had some Return to Work SA collaboration where you were taking GLITtER and taking it out into the public?

Yeah, so the GLITtER work that I published did meet with quite a lot of interest from researchers and for clinicians as well. There really seemed to be a bit of an unmet need in the clinical world for them to be able to have some tools to guide their clinical consultations and some supplementary resources to hand to their patients. So I have recently been involved in collaborating with Return to Work SA to do a second iteration of these GLITtER documents and I think they are now available online on the Return to Work SA website. So clinicians can download them, provide them to their patients and hopefully use them as they're meant to be used; which is to guide discussions around what their imaging findings show, around the what complexity of pain is. You know, we've talked a little bit about if scans don't show pain, what's the pain all about? So I'm just conveying the understanding that there's multiple contributors to a person's pain experience aside from just what's happening in the tissues and just what these scans show.

Is that part of the materials Emma?

Some dialogue tips and things like that are built in?

Yes. So there's some guidance with things that we could be talking about and discussions around the complexity of pain. There's some information that hopes to convey just the general benefits of activity and exercise, both in leading a full and active life, in assisting with pain as well, and in reducing the sensitivity of the nervous system, which we know is a factor with persistent pain.

And you're, you're looking to train some clinicians as part of your trial Tasha?

In these sorts of approaches because that's part of your trial, isn't it? An aspect of it?

That's right, yeah. So we're fortunate to get funding from NHMRC last year to run a large clinical trial looking at physical activity in people with osteoarthritis and looking at the influence of education. So basically testing different types of education. So at the moment, we're looking for private practice physiotherapists that would be interested, in either Adelaide or Melbourne, in taking part in this. And as part of that they would get, I feel a little bit arrogant saying this, but high level training. But training in some of the new methods of communicating pain science. But also then general training in providing and prescribing physical activity programs in people with osteoarthritis, because I think that is a nuanced activity as well. So it's a good area, I think, to upskill on. But it also as part of that, it does have a component of how we talk about imaging to people with osteoarthritis.

It's interesting, you were talking before Tasha about how common degenerative findings are in these asymptomatic people. So these are people who don't have current pain and possibly have never had current pain, who do show a high rate of degenerative changes, and we certainly know very similarly low back pain. Spinal images in asymptomatic populations show loads of degenerative changes; disc bulges, facet joint degeneration, are super common. And I guess another strategy when we're talking about widespread dissemination of information and avenues that that can come from, is whether or not the radiologist can actually be reporting on the imaging findings differently.

But don't have to put everything in? I thought that was one of the challenges with radiology reports?

Either it's a perception that they have to put everything in, or there's a legal requirement that if they see it, they need to write it down. Is that your understanding?

I don't have a complete understanding, but I certainly think radiologists are completely obliged to report what they see when they review an image.

It's not like they can do a one sentence report saying nothing. No important abnormality detected?

No. So those kind of scary phrases are going to be in those imaging reports, but I guess it's a matter of interpreting them in a way to de-threaten them if we can. In the online study that I undertook, where people were randomised to get imaging or didn't get any imaging, we further randomised people to receive some enhanced reporting or standard reporting. And what these enhanced reports involved was some descriptive information that was age relevant that described the normal findings, the normal degenerative findings. I guess people commonly assumed that degenerative findings and these phrases that sound abnormal on imaging are abnormal, but we actually understand now that that they're not necessarily always abnormal and that they're probably just better of thought of as ‘wrinkles on the inside’ or just normal occurrences that happen with ageing. And I guess interestingly, when you consider when you have a blood test, for example, you’re given the result of your blood test and then you’re given a bit of a range for what is normal. I guess there's no such reporting around spinal imaging, and what we tried to do was to convey that many of these changes are normal in the general population of that age. So we tried to contextualise, I guess, to convey an understanding of the amount of people without pain out there that did have similar findings on their scans. And the other thing we did in this enhanced reporting was we changed the summary; the wording that was used in the report summary. So many people do skip over those level by level changes that a spinal image reports and they just go down to the final comments at the end. So we thought we probably could get away with manipulating that, in that the radiologist had reported everything relevant in the age in the level by level report for [indiscernible]. So we changed some of the phrases in that summary report. We got rid of degenerative changes and we talked about them as being normal adaptive changes. And we conveyed the real importance of matching up what changes were identified on imaging, with the clinical presentation in their symptoms. And it's only through matching up those two things, that the relevance of the findings report on imaging can actually be accurately conveyed.

Did it have an impact?

Yes. So these enhanced reporting strategies lead to more reassured patients in this virtual patient scenario. So certainly it’s an avenue that could be explored more in the clinical world.

I love that idea. And I think it really highlights the importance of consistency and message, doesn't it? So that from the entire hierarchy – going from when, if they have undergone imaging and get a report, that right away this message is consistent among different health professionals. Because certainly when we went on Pain Revolution and we're going to rural and regional communities and talking to clinicians that are working there, one of the biggest points that came across to me was that people said, ‘Look, I'm talking to patients and I'm educating them about this type of stuff, but then they might go to this other health professional and they're hearing something completely different.’ And particularly when that other health professional might be someone like a surgeon who, we do know that often times information coming from different health professionals is prioritised based on their hierarchy. So surgeons are listened to and specialists are listened to very carefully, and it’s kind of taken as the truth. And so when we have that disconnect in messages, I think that's where that's really hard to be a patient. And it's hard to be the person treating that patient because you're almost fighting against the other health professionals, which is challenging. So I guess some of the strategies that I see that would be really important is really finding ways to keep that message consistent, whether it's through increasing training within some of the medical programs in terms of pain science knowledge, in terms of imaging, because I think it varies quite a lot. But some of the programs get very little training on this type of stuff. I know I won't say where my husband went to school, but he had one lecture on chronic pain from Chris Maher, and that was kind of about it when it came to back pain, despite it being one of the most common things people will consult for. How did you find Adrian, with consistency of message within an emergency department? That's a really complex situation.

It's really complex yeah. So obviously you've got multiple professionals working on cases in a very short period of time and communication can be lost when everything's so rushed. The other challenge with communicating to people about back pain. So obviously in EDs, this is where physios are being placed in EDs to try and take the burden off the waiting room, because so much back pain and muscular, simple musculoskeletal problems, are presenting. So a new model of care is having a physio do part of the assessment and treatment. But they're still working out how that model of care works. So sometimes it will be the ED doctor that sees the patient first and explains it and then they'll eventually end up at the physio. And the physio will listen to the explanation and go,’ Well that wasn't right’ and then give something different. And so, even in the one health care setting, you're getting different messages. One thing my colleague has been doing, is doing an implementation study in EDs where he's doing clinician training. So this is nurses, allied health, ED doctors. I don't think many of the neurosurgeons attend. But that's sort of a multi-disciplinary training program across New South Wales hospitals. And it's tough to do. It's a tough study to do. To train all these people. To give these messages about guideline based care and appropriate use of imaging. You’ve got to go out and train them and then within a month or two, the doctors rotate. So then you've got to do it again. So we're thinking through, or my colleague Gustavo Machado's based at Sydney Uni where I'm based, and he's completed that study, which is a randomised trial of 4000 people with back pain presenting to ED. So it's going to be interesting to see what they find with how they went with the clinician education strategies because that was a key bid: was to try and get consistency in the care in one setting. But then you know there's the complexity of those patients going back out to primary care and getting a different explanation. But I fully agree with you Tasha; the medical programs need to change. I've taught in medical programs recently and it's disappointing how little is dedicated to musculoskeletal pain. And I think that would be, you know, nationwide if we increased training in. There are modules on overdiagnosis, which is fantastic to see, so that's starting to increase. There's not much on pain. Not much on appropriate use of imaging. And GPs have got so many other things they need to think about, that it's hard to cover everything in depth, but we're getting to the point where we may need to reprioritise things.

Do you think Adrian, that incentivisation of longer consultations is a necessary part of this to allow GPs to convey the information that they need to in the clinical consultations?

I definitely think that will help. The evidence suggests that the shorter the consultation, the more likely a patient is to get an opioid. And there's no direct evidence, but I would expect that imaging rates would be higher in shorter consultations because it's a way of getting people through the door. Patients are happy when they leave with a strong painkiller and a test to see what's wrong. Great, out in 5 minutes. To sit down and explain why someone doesn't need imaging takes longer than 5 minutes. So I think we need to support GPs to give them the time that it takes to provide really good education and advice, and I think that would be good investment for the government. What do you think, Tasha?

Yeah, I'm, I always feel slightly torn on this. I see the merits, certainly in longer appointments with GPs. I would be really interested to see their comfort level with that. So if say, for example, if they knew that there was a resource such as a 1 ½ or a 45 minute, 1 hour consult with a physiotherapist, that they could refer to who was really comfortable in going through this and talking about this type of information and they were the ones to prime it. So they were to say, ‘Look, actually, we've had new knowledge in this area. I want to send you to one of the people that are the best to talk to you about this and that can take the time. Let's follow up in a week and let's talk about what you heard.’ Because I think there maybe is flexibility for integration of different roles within that. Because certainly in trying to engage GPs, it's been really hard, and that's not judging them. Like you said, they're so busy. They have so many things on their plate. They have so many things that they have to be aware of and picking up serious conditions and referring as possible. So if this is something that's slightly outside of their skill set and they're not comfortable with engaging in and feeling like they know all the information and they're giving the proper advice, that I think maybe that might be a really unique role for physiotherapy to be someone that would be referred to and go through this fully.

Yeah, I absolutely agree with that point, Tasha. And I guess that GPs still need to take a lot of responsibility just for those words that they choose and the brief messages that they deliver in those early consultations, because we know how powerful they can be. Firstly, because they're coming from a GP who they may hold in a position of higher authority. But just healthcare messages can have such a resounding impact on a person's beliefs about their prognosis and their understanding of that.

And you're so right because it's often always those little throwaway comments that just stick for people. We had a couple people come to the brain bus when we were doing Pain Revolution and they came and they said, ‘Oh my GP took a look at my X-ray and just said, Huh! Oh, that's the worst I've ever seen. That's the back of an 80 year old.’ And, unfortunately, the person wasn't 90 which would have been a compliment. So I think it's a challenging thing in that sense, but absolutely that is probably getting onto this on numerous fronts, isn't it?

But it's also elevating physios to be, you know we're front line practitioners already. But I don't want to sound competitive with the GPs, but it might be time to start restructuring the health system so that, for example, workers compensation claims, I don't think necessarily need to go through a GP and then to a physio. So we're sort of the second line approach. That really good quality advice early on in a consultation would happen if physios could screen these patients first. We don't necessarily need to have a culture where GPs are the ultimate authority. Well surgeons are sort of the top, but then GPs are probably really credible sources of information. But I think that's partly to do with some of the structure in our health system that might need to change. Now I think we need to evaluate it as well. So I think we don't need to have a mad rush of everyone going to see a physio for everything because that could cause overtreatment as well. So I always have my overdiagnosis hat on there. Physios aren't immune. But I also think, we are very skilled. Like you said, and I thought you put it beautifully Tasha, that we're really skilled in this early education that can be done in 1 or 2 consultations. The health system is not going to collapse and it could prevent; we have evidence, high quality evidence from systematic reviews, that early education for acute low back pain reduces health service use in the subsequent 12 months. So it's probably going to be a good investment and it doesn't need to be a 45 minute consultation. It could be shorter. But it's the quality. It's the quality that I think is key.

Yeah, and I think that those messages that people get in the quality of those messages potentially also has intersection with other areas. Because if it's leading and developing beliefs about what's wrong and what's going on, it also then potentially shapes what they're going to expect in terms of what treatment they should get. So if they have these thoughts that you know, ‘This is all, everything's broken. This is, you know, hurts, it's not working’. Our jobs as physios is to try to convince people that probably exercise is the very best thing for them, which you know resoundingly that's what the evidence shows. That's really hard. It's really hard because, how do you convince someone that you should be doing things on something that's broken?

It is. So I think having these high consistent and high value messages can be really powerful, not only just in that initial encounter, but in the sequelae of what we see in terms of maybe even treatment compliance, treatment adherence. I do think that there could be some really important effects of that that we might not see right away, but they might be longer term down the road effects. I think the way that possibly physios interpret and the way they use information from scans probably varies quite a lot. So they're certainly is, I think, value in looking to upscale our profession in how to do it, because I guess one of the key things is the comfort that you feel with doing something like that. So if you as a person, as a health practitioner, are not really sure if this stuff, ‘You know well, maybe this is true, but maybe it's not.’ The ability to communicate that with confidence and with reassurance, I don't think that's going to happen. And I think until you probably get the chance to ask hard questions and to really delve into the research and maybe pick the brains of experts like Adrian and Emma, those doubts perhaps might still be there. Because I don't think it's an easy thing to do. I don't want to downplay at all how hard, sometimes challenging, these types of very held deep beliefs, actually is to do.

Yeah, there's probably scope to develop resources that can be used across conditions. We've tried to do that. We haven't nailed it down yet, but there's so much overlap between knee OA (osteoarthritis) and low back pain and other conditions where the prevalence of abnormalities on imaging is very high and that there's this tendency of these findings to possibly drive overuse of invasive treatments like surgery and injections, and those sorts of things. But we're still trying to figure out what a patient is more likely to use and what a clinician is more likely to use. Would they prefer condition specific materials or a generic resource? And the initial data we have is that those conditions specific ones are preferred. But I still think there's scope on a public health level to communicate broadly about overdiagnosis and the fact that having a scan, it does have these things that you should consider before you decide to go down that road.

I think it's really interesting because I think a lot of the materials that we've been talking about have been sort of educational materials. And one of the things that I guess I always find intriguing is: people will tend to come into a consult - so even for some of the clinical trials that we're screening from - and sometimes the information that dictates or guides their choice the most is, ‘Oh, my neighbour told me this and told me to try this and said it really worked for him or her.’ And so I wonder whether there's value in identifying patient champions that have gone through. They've done well. They've learned some really key lessons that they felt were important to their recovery and almost be able to pair people with them. It wouldn't work in an emergency department. Gosh, can you imagine trying to organise that? But I mean, I wonder with some of the more longer term clinical encounters, whether there's some merit? Because certainly some of Professor Jennifer Stinson's work. She does a lot of stuff with paediatric pain and looking at apps. And I know they had a program where they were pairing people; kids with mentors that were a little bit older, that had been through almost that adolescence transition of trying to deal with a chronic pain condition. And they found that really useful. So, I'm interested to see what the future holds, for how we can revolutionise these methods and really use social dynamics and connectedness to our advantage in this.

That's an amazing idea because the healthcare encounter, it’s complex. It's not just about throwing information at people. And I think ultimately we're trying to empower people to take charge of their care but that's not a simple process. And there's a lot of variation in health literacy and numeracy and the ability to understand risk. So even a generic education resource may work for some people who are health literate, but it's hopeless for another person or from people from CALD (Culturally and Linguistically Diverse) backgrounds, linguistically diverse backgrounds. So the idea of champions is another way of empowering people to self-manage and to navigate a really complex health care system and not find themselves being overdiagnosed and over treated.

That was Adrian Tragaer, Tasha Stanton and Emma Karran and you've been listening to another episode of Talking Physio. One final thank you to Flexeze and the Physiotherapy Research Foundation for helping us to produce this podcast. Stay tuned for another episode very soon. Thanks for listening.

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