Spinal pain: current understanding, trends, and the future of care

Abstract

This commissioned review paper offers a summary of our current understanding of nonmalignant spinal pain, particularly persistent pain. Spinal pain can be a complex problem, requiring management that addresses both the physical and psychosocial components of the pain experience. We propose a model of care that includes the necessary components of care services that would address the multidimensional nature of spinal pain. Emerging care services that tailor care to the individual person with pain seems to achieve better outcomes and greater consumer satisfaction with care, while most likely containing costs. However, we recommend that any model of care and care framework should be developed on the basis of a multidisciplinary approach to care, with the scaffold being the principles of evidence-based practice. Importantly, we propose that any care services recommended in new models or frameworks be matched with available resources and services – this matching we promote as the fourth principle of evidence-based practice. Ongoing research will be necessary to offer insight into clinical outcomes of complex interventions, while practice-based research would uncover consumer needs and workforce capacity. This kind of research data is essential to inform health care policy and practice.

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Journal of Pain Research 2015:8 741–752
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Open Access Full Text Article
http://dx.doi.org/10.2147/JPR.S55600
Spinal pain: current understanding, trends,
and the future of care
Gregory F Parkin-Smith1
Lyndon G Amorin-Woods2–4
Stephanie J Davies5–7
Barrett E Losco8
Jon Adams9,10
1General Practice, Surgery 82,
Busselton, WA, Australia; 2S cho ol
of Health Pro fessions, Mu rdoch
University, Murdoch, WA, Australia;
3Chiropractors’ Association of
Australia, Nedlands, WA, Australia;
4ACORN Project, 5WA Specialist
Pain Services, WA, Australia; 6School
of Physiotherapy, Curtin University,
Bentley, WA, Australia; 7Sch ool
of Medicine and Pharmacology,
University of Western Australia,
Crawley, WA, Australia; 8Murdoch
University, Murdoch, WA, Australia;
9Faculty of Health, University of
Technology Sydney, Ultimo, NSW,
Australia; 10Australian Research
Centre in Complementary and
Integrative Medicine, University of
Technology Sydney, Ultimo, NSW,
Australia
Correspondence: Gregory F Parkin-Smith
General Practice, Surgery 82, 82 Bussell
Highway, Busselton, WA 6280, Australia
Email g.parkin.smith@gmail.com
Abstract: This commissioned review paper offers a summary of our current understanding of
nonmalignant spinal pain, particularly persistent pain. Spinal pain can be a complex problem,
requiring management that addresses both the physical and psychosocial components of the
pain experience. We propose a model of care that includes the necessary components of care
services that would address the multidimensional nature of spinal pain. Emerging care services
that tailor care to the individual person with pain seems to achieve better outcomes and greater
consumer satisfaction with care, while most likely containing costs. However, we recommend
that any model of care and care framework should be developed on the basis of a multidis-
ciplinary approach to care, with the scaffold being the principles of evidence-based practice.
Importantly, we propose that any care services recommended in new models or frameworks
be matched with available resources and services – this matching we promote as the fourth
principle of evidence-based practice. Ongoing research will be necessary to offer insight into
clinical outcomes of complex interventions, while practice-based research would uncover con-
sumer needs and workforce capacity. This kind of research data is essential to inform health
care policy and practice.
Keywords: back pain, pain management, combined modality therapy, patient care team
Background
A large body of research now exists related to the treatment of nonmalignant spinal
pain, with literally hundreds of reports on clinical trials showing the benefit of the
treatments under investigation. For example, Hurwitz1 indicated that there were over
200 reports on clinical trials related to spinal manipulative therapy and exercise for low
back pain alone, with several other conservative treatments also being recommended in
published clinical guidelines2–4 and systematic reviews for nonmalignant spinal pain.5–7
Well-known and widely accepted treatments, with at least a moderate benefit,8 include
advice and education,9 returning to work,10 being active,11,12 exercise,13,14 and manual and
manipulative therapy, among others.15,16 Nonmalignant neck and thoracic pain should
also be mentioned here as very common problems, again with the research evidence
offering insight that similar conservative treatment(s) have a beneficial effect.17–19 In
fact, a cross-sectional, nation-wide survey of the Danish population showed remarkably
similar patterns in pain reporting and the consequences of pain for the three spinal
regions (cervical, thoracic, and lumbosacral), respectively.20 The implication is that
nonmalignant spinal pain may be considered as essentially the same condition regard-
less of the region of the spine involved. Therefore, we can reasonably speculate that
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Parkin-Smith et al
interventions shown to be of benefit for low back pain are also
likely to be effective for pain in other areas of the spine.
It is now questionable whether further research into
existing individual treatments for nonmalignant spinal pain
would add to our current understanding. Updates of well-
known, published clinical guidelines and systematic reviews
encourage specific effective treatments that were shown to be
useful for the specific cohort of patients recruited to each of
the reviewed studies. Furthermore, we know from experience
and published trials21–23 that health care practitioners, quite
reasonably, combine treatments in an attempt to offer patients
the best possible outcomes with respect to their pain. Often,
treatments are prescribed or delivered together, such as simple
analgesics and advice, or a combination of education, exer-
cise, and manual and manipulative therapy. The aim is to take
advantage of the plausible synergistic effects of these treat-
ments, often with greater patient satisfaction with care.24,25
For example, in the United Kingdom Back Pain Exercise
and Manipulation (BEAM) trial exploring low back pain of
more than 4 weeks duration, the number needed to treat for
spinal manipulation for nonmalignant low back pain is 5.4
and for exercise is 5.0, thereby presenting either treatment as
an attractive option for clinicians, patients, and policy makers.
Yet, if a package of care is used, such as combining spinal
manipulation followed by exercise, this results in a number
needed to treat of 3.3,26 which is even better.
Spinal pain, particularly persistent pain, is a complex
phenomenon, and it is very real to the person experienc-
ing it. Persistent pain has both physical and psychosocial
components.27,28 Accordingly, there is an evolving trend toward
matching care to both the physical and psychosocial compo-
nents of a patient’s pain experience. This implies determining
the patient’s care needs, be these physical and/or psychosocial,
and matching them with the best available evidence-based
active and passive treatments. In conjunction, care services
and access to these services need to be identified and devel-
oped to meet the patient’s care needs. The end product is a care
package or protocol that is tailored to the individual patient,
ranging from low to high levels of care complexity, with a
view to gaining the best possible outcomes. This approach to
care would be achieved through multidisciplinary health care
teams and utilizing a multimodal, biopsychosocial approach to
care – this approach now being reflected in emerging innova-
tive Models of Care (MoC) and Care Frameworks.
The health care demand issues facing developed countries
are well-known, particularly related to the needs of an aging
population, chronic disease, sometimes ailing workforce,
and dramatic cost inflation.29 Therefore, the emerging
focus in health care is to have care services delivered using
mechanisms or strategies that are cost efficient and evidence
based,25,30 wherever possible, while engaging with the broad-
est applicable workforce. In the past, clinical guidelines have
attempted to do this, but, as stated in the Australian National
Health and Medical Research Council (NHMRC) report31 on
the utilization and adherence to clinical guidelines:
Governments have funded 22% of the guidelines in this
report, yet there remains a demonstrable lack of coordina-
tion in the way guidelines are prioritised and commissioned
in key clinical areas … [and] … Effective implementation
of guidelines still remains a key challenge for guideline
developers and funders ….
The message is that nonadherence to guidelines have
led to limited implementation, which is speculated to have
significant cost and resource implications for health care
systems.
The problems with adherence and implementation of
clinical guidelines are well known.32 This does not imply
that guidelines are of poor quality or that their outcomes
are meaningless. On the contrary, the problem lies with the
implementation of guideline recommendations in real-life
practice, not the quality of the guideline in itself. Indeed,
another neglected aspect is acceptability of guideline rec-
ommendations to the end user, be it the clinician, manager,
policy maker, academic, or consumer, respectively.33,34 A fresh
model is needed that goes beyond clinical guidelines to
facilitate the adherence and implementation of recommended
care, where the content, layout, format, and illustrations are
tailored to the user and their context.
In addition, reviews and guidelines offer little insight
into the multidisciplinary activities necessary, within the
context of the biopsychosocial model of pain management,
to successfully deal with the problem of persistent spinal
pain. With the spotlight now on multidisciplinary care, we
highlight the necessary involvement of various health care
providers. This is auspicious, since this broadens the work-
force capacity to manage the growing problem of spinal pain
through teamwork and task substitution, thereby potentially
avoiding the huge cost and effort to train new graduates and
future practitioners in the area of spinal pain.
The purpose of this paper, drawing specifically upon the
Australian context and experience, is to offer the reader a
review of the care services and pain management approach
that is likely to facilitate the successful management of non-
malignant spinal pain. To achieve this aim, the objectives are
to offer: 1) a précis of our contemporary understanding of

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Spinal pain: a review of care
the treatments for nonmalignant low back pain, supported
by the best available research evidence; 2) a description of
the biopsychosocial model, which is the emerging scaffold
for current care services; 3) to show how the biopsychoso-
cial approach may be represented in a Model of Care; 4) to
briefly describe how the whole workforce relevant to spinal
pain may be rallied to provide care services; and 5) to share
our insights into the potential features of future care services
and associated research.
We acknowledge that pain states may be acute, subacute,
and chronic. However, it is beyond the scope of this paper to
provide an account of each of these categories, even though
these categories share many similar characteristics,35 because
the ideas as set out in this paper may be generalized across
all three categories.
Update on the research evidence
Recommendations on treatments for acute and chronic spinal
pain are published elsewhere in numerous reviews and clini-
cal guidelines. We emphasize that guidelines seldom offer
a full account of either 1) exactly how each recommended
treatment should be applied, or 2) if a specific combination
of these treatments would be more useful than another. In
this regard, more recent research is showing that treatments
previously believed to be equivocal are now emerging as
clearly beneficial. For example, in a randomized controlled
trial testing guidelines-based care, Bishop et al36 showed
that significantly greater improvement for acute mechanical
low back pain of 16 weeks, or less, was achieved with spinal
manipulative therapy compared with usual medical care.
Patients receiving usual medical care had inferior functional
outcomes in conjunction with higher rates of prescribed opi-
oid analgesics (80%). The COST B13 European guidelines37
differentiate between supporting the use of weak opioids
(eg, tramadol), for acute and chronic back pain, and do not
mention strong opioids for acute back pain. The COST B13
guideline indeed comments on the limited evidence for strong
opioids in chronic back pain.
There is strong evidence that weak opioids (eg, tramadol)
relieve pain and disability in the short-term in chronic low
back pain patients (level A). There is limited evidence that
strong opioids relieve pain in the short-term in chronic low
back pain patients (level C).
Furthermore, medically managed patients received a high
percentage (60%) of guideline-discordant treatment, like bed
rest, X-rays, and back supports. Goertz et al38 demonstrated
that spinal manipulative therapy in conjunction with standard
medical care offers a significant advantage for decreasing pain
and improving physical functioning when compared with
standard care alone for men and women between 18 and 35
years of age with acute low back pain. In contrast, Hay et al39
showed that a brief pain management program for back pain
delivered by appropriately trained clinicians offers an alterna-
tive to physiotherapy-incorporating manual therapy and could
provide an efficient first-line approach for subacute low back
pain in primary care. The inferences from these trials37–39 are
that there are various effective treatments for nonmalignant
spinal pain, and that a multimodal approach, combining inter-
ventions, is likely to yield better outcomes – in this case patient
education with both active and passive treatments. Such
studies, among others, also firmly support the early access of
patients with nonmalignant spinal pain to assessment, with an
emphasis on triage and diagnosis, and appropriate treatment,
to achieve the best possible outcome.37–39
Fortuitously, research exploring the outcomes of a com-
bination of treatments is now emerging in the health care
literature and in practice across many health care sectors. For
example, a before-and-after clinical trial of a multimodal treat-
ment program for hip and knee arthroplasty led to a shorter
duration of stay when compared to usual care.40 Of course, we
acknowledge that care pathways and treatment protocols have
been around for some years in specific health care disciplines,
including pain medicine,41 but only more recently have there
been earnest attempts to examine these protocols in definitive
studies using appropriate research design to test these complex
interventions. Patrick et al42 showed that multidisciplinary treat-
ments for chronic pain are superior to no treatment, waiting list
(patients waiting to be consulted by a clinician, not yet having
received any treatment), as well as single-discipline treatments
such as medical treatment or physical therapy. Moreover, the
effects appeared to be stable over time. The beneficial effects of
multidisciplinary treatment were not limited to improvements
in pain, mood, and cognitive interference (unwanted and often
disturbing thoughts that play an important role in stress, poor
performance, slow learning, social maladjustment), but also
extended to behavioral variables such as return to work or use
of the health care system.
We propose that multimodal, multidisciplinary care has
a beneficial effect on nonmalignant spinal pain and is an
approach to care worth pursuing. For example, Monticone
et al,43 in a clinical trial of a multidisciplinary rehabilitation
program on disability, kinesiophobia, catastrophizing, pain,
quality of life, and gait disturbances in patients with chronic
low back pain, showed that a multidisciplinary rehabilitation
program including cognitive behavioral therapy was superior

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to an exercise program. Moradi et al44 showed that multidisci-
plinary treatment ameliorates pain, improves both functional
restoration and quality of life, with medium to high effect sizes,
even for patients with a long history of chronic back pain.
Effect sizes are higher than for monodisciplinary treatments,
and treatment effects remained stable at 6-month follow-up.
Moradi et al44 conclude that multidisciplinary treatment is vital
for the management of patients with chronic low back pain.
Published research protocols of trials currently being
implemented promise exciting outcomes. In a proposed
Danish study, guidelines on low back pain management are
being tested in a clinical trial.45 The expectation is that the
implementation strategy will reduce the number of patients
referred to secondary care, and that the additional upfront
cost of extended implementation will be counterbalanced
by improvements in clinical practice and patient-related
outcomes, thereby rendering the strategy cost efficient. In
another proposed randomized controlled clinical trial in
working-age patients with chronic low back pain,46 three
treatment strategies are to be compared: 1) intensive and
multidisciplinary program conducted in a rehabilitation
center, 2) less intensive outpatient program conducted by a
private physiotherapist, and 3) a mixed strategy combining
the same outpatient program with a multidisciplinary inter-
vention – the hypothesis is that a multidisciplinary approach
will be the key feature of success in reducing social and
occupational impairment. Therefore, it may be possible to
achieve the same positive results with less intensive strategies
if a multidisciplinary approach is maintained.
The clear message from current and emerging research
is that multidisciplinary care is very likely to have a major
positive impact on clinical outcomes, patient satisfaction
with care, and cost savings. In this regard, development
of MoC or care service frameworks needs to incorporate
the principles of evidence-based health care, which are:
1) use of the best available research evidence, 2) inclusion
of clinical expertise, and 3) acknowledgment of consumer
preferences.47 We also propose the fourth “leg” or principle
of evidence-based health care, which should be the careful
consideration of available resources – (sustainable) funding,
resources, access, and workforce capacity – otherwise even a
well-designed framework or model would neither be feasible
to implement nor acceptable to end users.
The multidimensional nature of pain
The International Association for the Study of Pain defines
pain as “an unpleasant sensory and emotional experi-
ence associated with actual or potential tissue damage, or
described in terms of such damage”.48 Therefore, the concept
of pain can be complex and difficult to grasp. As a multi-
faceted phenomenon, pain requires a versatile approach to
care, with a view to achieve the best possible outcomes.49
Nonmalignant spinal pain, particularly persistent pain, is no
different and should be considered under the umbrella of the
pain conundrum. Unraveling the puzzle of pain starts with
each person who has persistent pain becoming aware of the
interlinking contribution of injury pain (thought of as noci-
ception), neuropathic pain, inflammatory pain, and increas-
ingly, the likelihood of immunoreactive component(s).50 The
emphasis here is that pain is complex and requires a likewise
multifaceted approach to care. We feel that a patient-specific
approach drawing upon the expertise of multiple health care
disciplines is emerging as the best practice approach.
The biopsychosocial model of care, which is character-
ized by multidisciplinary, multimodal care, is now a widely
accepted strategy for the management of persistent pain.27,28
For example, a systematic review suggested that there was
moderate evidence that multidisciplinary rehabilitation was
effective for subacute low back pain.51 This multidisciplinary
approach with “whole person engagement” is now gaining
acceptance as an important way of connecting with and
managing persons with pain because there are interdependent
relationships between the physical and psychological fac-
tors associated with pain52 that require a holistic approach.
Epidemiological studies have also highlighted that the
psychosocial factors linked with low back pain can be used
as prognostic indicators, eg, depression.53,54 These studies
highlight the need to target care toward both the deleterious
physical and psychosocial aspects of pain.
The management of pain is a bit like a jigsaw puzzle,
with medications or procedures only representing one of the
pieces of a multipiece jigsaw of cocare, multimodal options.
So far, current care services may not be measuring all the
pieces of this jigsaw puzzle entirely. For example, Froud
et al,55 in a systematic review and meta-analysis, indicated
that the impact of the experience of persistent pain on the
affected person is profound, yet they found that despite the
suffering being significant, core outcomes often did not
capture what was important. Froud et al55 suggest a move
toward a biopsychosocial model that covers core sets of
relevant outcomes. Cocare, via multidisciplinary working
teams,56 implies coordinated care between knowledgeable
consumers and a range of health care providers, each repre-
senting pieces of the puzzle,57 with a view to bring the pieces
together and develop a beneficial management plan tailored
to the individual person with pain.

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Now, more than ever, coordinated action is needed to plan
for the short- and long-term care needs of persons with pain.
In the past, care services for pain have been quite discrete
and have not taken full advantage of the benefits of the mul-
tidisciplinary approach to care. Contemporary management
of pain is evolving toward this multidisciplinary way, with a
view to obtain better outcomes. However, there are still bar-
riers, including local health care politics, workforce capacity,
funding mechanisms, and the gap in explicit MoC that are
designed to guide care in real-world practice.
The economic cost of spinal pain
The importance of addressing spinal pain in a cost-effective
and clinically appropriate manner is illustrated in a series of
studies emerging from the Global Burden of Disease 2010
Project.58 It is well-known that musculoskeletal conditions,
such as low back pain, neck pain, and arthritis, affect more
than 1.7 billion people worldwide and are set to become
more prevalent in the developed world with a growing aging
population.59 Pain is now recognized worldwide as an area of
health care need and, in Australia, it is emerging as a national
priority.60 Chronic pain is the third most costly condition in
annual health expenditure in Australia ($34 billion).61 The
number of people living with chronic pain in Australia is esti-
mated to increase from 3.2 million in 2007 to 5.0 million in
2050.62 Much of this persistent pain would be spinal pain.
A major reason for escalating health care expenditure
relates to treatment and investigation cost inflation – annual
expenditure for spinal pain management in 1995 in the
United States was calculated to be US$7.3 billion, whereas
in 2007 the cost for drugs had skyrocketed some 271% to
US$19.8 billion, accounting for a sizable 23% of total direct
health care expenditures. These trends are being reflected
in Australia.63 Major elements accounting for this increase
include the wider use of expensive drugs, spinal injections,64,65
and/or unnecessary investigations.
A systematic review of the cost-effectiveness of
guideline-endorsed treatments for low back pain, in which
26 studies were appraised,66 demonstrated that spinal manipu-
lation, interdisciplinary rehabilitation, exercise, acupuncture,
or cognitive behavioral therapy all were cost-effective in
individuals with subacute or chronic low back pain, while
no evidence was found in support of medications, yoga, or
relaxation.66 Furthermore, the same study indicated that care
from a general practitioner did not appear to be the most cost-
effective means for managing low back pain, considering that
adding spinal manipulation, exercise, behavioral counseling,
and education/advice were more cost-effective than usual
care from a general practitioner alone.66 Another systematic
review by Michaleff et al67 supports the cost-effectiveness of
spinal manipulative therapy, either alone or in combination
with other treatment approaches. A convincing example of
how a multidisciplinary, multimodal approach is likely to be
more cost-effective than “standard” care for persistent pain
is highlighted by the results obtained by Lin et al,64 showing
that a package of evidence-based treatments, which included
spinal manipulation, is cost-effective for subacute and chronic
low back pain and at least as cost-effective as other forms of
conservative treatment. Recent Workers’ Compensation data
from USA suggest that patients with occupational spinal
injuries visiting a surgeon first are significantly more likely
to receive spinal surgery (42.7%) than those whose first visit
was with a musculoskeletal clinician (1.5%).68 This asso-
ciation holds true even when controlling for injury severity
and other measures, implying a significant cost saving and
emphasizing the importance of fast access to appropriate
assessment and care, so that best practice care may commence
at an early stage of the disorder. Importantly, on synthesis
of the outcomes of these studies, we do not suggest that any
specific treatment should necessarily be viewed as inferior,
but rather the importance of accurate triage and diagnosis,
followed by appropriate care, is emphasized.
Care approach and avoiding
chronicity
Research evidence supports the early referral and assessment
of spinal pain patients by an appropriate health care practi-
tioner, this may be a general practitioner or pain physician,
but in the future may also include other trained and vetted
clinicians, such as clinical nurse specialists, chiroprac-
tors, osteopaths, physician assistants, and musculoskeletal
physiotherapists, with a view to offer treatment, facilitate
health promotion, support rehabilitation, and offer patient
education, ie, to apply the right treatment at the right time
and in the right place.69 Early referral and assessment also
has potential cost savings by avoiding unnecessary imaging/
investigations, hospitalizations, medical procedures, and
surgery.70 Needless to say, health care policy- and decision-
makers would be very interested in any approach that may
save on costs, which could be as much as a 20% saving on
current expenditure for low back pain care within the main-
stream health care sector.63
The importance of early access to appropriate care cannot
be underestimated, since the aim of appropriate care is to alter
the course of the disorder, particularly since low back pain is
well-known to be either episodic or progress to chronicity.71

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Hestbaek et al72,73 indicated that low back pain has an episodic
trend in up to 80% of cases, as opposed to resolving fully,
and Henschke74 reported that up to 30% of acute back pain
becomes chronic. Around 25% of Australians who experi-
ence low back pain continue to have persistent or recurrent
episodic back pain.75 Indeed, in a cohort of patients with acute
low back pain in Australian primary care, prognosis was not
as favorable as claimed in clinical guidelines – recovery was
slow for most patients and nearly 33% of patients did not
recover from the presenting episode, implying chronicity
and added health care costs.74
Appropriately trained health care professionals could
facilitate access to care at a community level and also identify
predictors of chronicity in affected patients,71 which could
subsequently be addressed through health/lifestyle modifica-
tion and utilization of local healthy lifestyle programs, and
could be as simple as a 20–40-minute walk a few times per
week.76,77 For example, a package of care using the latest
evidence-based management, including patient education,
staying active, exercise including a daily walk, lifestyle modi-
fication, spinal manipulative therapy, and simple analgesia,
is likely to yield the best possible outcomes.24 This “package
of care” approach would be particularly useful if combined
with existing and currently funded programs focusing on
lifestyle change and chronic pain prevention, such as the
(Australian) Medicare Local (now Primary Care Network)
Healthy Lifestyle and Chronic Pain Program and the Self-
Training Educative Pain Sessions (STEPS) program, with
the goal of preventing chronicity.38,49,78
Short-term or periodic use of simple analgesia for mild-
to-moderate acute spinal pain (paracetamol, nonsteroidal
anti-inflammatory drugs [NSAIDs]), and weak opioids such
as tramadol for acute, moderate-to-severe spinal pain of
less than 2 weeks is clinically defendable, notwithstanding
recent evidence concerning the effectiveness79 and toxic-
ity80 of paracetamol. Some clinical guidelines recommend
the limited use of strong opioids such as buprenorphine,
morphine, and oxycodone, as the evidence of effectiveness
is low (Level C),37 while the potential for harm is real. The
use of benzodiazepines which interfere with memory should
be limited. The guidelines support the use of paracetamol,
NSAIDs (less than 3 months), and weak opioids, such as
tramadol, in combination with paracetamol.37
The Musculoskeletal Analgesic Regime to Aid Rehabilita-
tion (MARTAR) regime, developed by the WA Emergency
Medicine Research Online (WAEMRO), suggests a graded
approach to prescribing opioid analgesics is recommended
based on the severity of the back pain (usually presenting in
the emergency department as severe, acute back pain) over the
short-term (short-term implying 2 weeks or less).81 Depending
on the severity of pain, the MARTAR regime recommends
various analgesics, including oxycodone immediate-release
(IR) and morphine, alongside benzodiazepines such as clon-
azepam and diazepam. The regime emphasizes, however, that
evaluation of the person with pain should occur #4 hourly and
analgesics titrated accordingly. Outside of the acute hospital
setting, we do not recommend the regular use of potentially
addictive opioid analgesia, such as oxycodone, pethidine, or
morphine, for severe pain, but rather less addictive analgesics,
such as tramadol (Schedule 4, prescription only medication).
If a strong opioid is considered, then buprenorphine (Sched-
ule 8, controlled medication, requiring prescription and the
prescribing is audited) is the least harmful effective option82,83
as it is the only strong opioid not associated with rapid toler-
ance, opioid-induced hyperalgesia,84 lowering of the person’s
sex hormones,85 or a negative impact on the patient’s immune
system via inhibiting their natural killer cells. In addition,
buprenorphine has both an analgesic and antihyperalgesic
effect82 which is relevant in neuropathic pain, which can be a
contributor in spinal pain.86
Strong opioid drugs (S8) and benzodiazepines are asso-
ciated with much higher risks and complications related to
tolerance, addiction, and abuse, particularly with chronic or
recurrent spinal pain syndromes.87,88 The problems associated
with opioid use seem to emerge predominantly outside of the
acute hospital setting – prescriptions for oxycodone in Austra-
lia have increased by more than 150% in the 5-year period up
to 2008, with 551 Australians dying as a result of accidental
overdose of prescribed opioids in the same year.89 An esti-
mated 1,300 Australians aged 15–54 years died from acci-
dental overdose of prescribed opioids in 2009/2010 – “most
of the existing guidelines have limited impact on what is now
approaching a national epidemic”.90 Except for the short-term
treatment of acute, severe cases of back pain, where opioid
and benzodiazepines are a defendable option, there is little
evidence to suggest that full µ-agonist opioids change the
course or severity of back pain37 to date. Compounding the
matter are patients who put their doctors under pressure
to prescribe opioids, often leading general practitioners to
overlook behavioral nonpharmacological clinical guideline
recommendations for nonmalignant pain.91
By extrapolation, a key area for undergraduate training of
health care professionals, especially pharmacists and doctors,
would be to increase the knowledge with clinical guidelines,92 i n
the aim to increase guideline-concordant treatment. We advocate
assessment and treatment of the person with spinal pain by an

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appropriate, vetted, trained guideline-concordant health care
professional, with a view to triage, diagnose, and manage acute,
mild–moderate spinal pain and attempt to prevent chronicity.
Health care politics and available
workforce
The immense burden and cost of conditions resulting in per-
sistent pain in Australia is eloquently summarized by Briggs
et al.93 There are various journal editorials that suggest a bumpy
road ahead regarding health care funding, a common theme
across the globe, and ongoing concerns about how politicians
and health care decision makers will define or determine
“health”.94 Therefore, when making recommendations about
care in any future model or framework of care, it will be
imperative that resources (sustainable funding, access to care,
and workforce capacity) become the fourth principle, or “leg”,
of evidence-based practice, receiving equal attention in clini-
cal, academic, and policy decision-making. Any recommended
evidence-based treatment simply cannot be delivered if the
resources and sustainable funding is not forthcoming.
Health care workforce analysis by the Australian Pro-
ductivity Commission highlighted the desirability of “task
substitution”95 and a recent new-graduate health care practitio-
ner survey identified emerging health care workforce capacity
that could cater for the multidisciplinary community-based
approach for nonmalignant spinal pain,92 with the proviso
that the health care professionals were trained, and poten-
tially monitored, for clinical guideline concordant care. In
particular, appropriately trained health care professionals
such as clinical nurse specialists, chiropractors, osteopaths,
physician assistants, and musculoskeletal physiotherapists,
in addition to the traditional practitioners engaging with pain
management, could be counted as part of the health care
workforce. These additional health care disciplines would
be able to fill some of the workforce gaps.
Goals and process of spinal
pain management
MoC (Model of Care) can help to address the burden of
service gaps in musculoskeletal health.30 An MoC is an
evidence-based strategy, framework, or pathway that out-
lines the optimal manner in which care for specific types or
groups of conditions should be made available and delivered
to consumers. An MoC aims to
… include contemporary evidence with a framework to
meet the current and projected community needs, within
the context of local operational requirements.93
Importantly, an MoC is not an clinical practice guide-
line.30 Attention needs to be given to not only effective
evidence-based management but also to other factors, such
as poor lifestyle, lack of exercise, and patient education. In
addition, management of persistent and/or complex spinal
pain requires timely follow-up and ongoing consumer partici-
pation in their care, which usually needs ongoing supervision,
ie, coaching. Management of a person with pain is, therefore,
a series of ongoing activities that requires continuing input
and participation by both the consumer and the multidisci-
plinary health care team, respectively. Guidelines on these
activities would be included in an MoC document, thereby
offering an outline of consumer’s care journey.
The goals, then, of an evidence-based MoC would be to:
1. Broaden care services to span from hospital-based to
community-based services with a view to improve and
facilitate earlier access to care, embrace a wider relevant
workforce, and contain costs by attempting to avoid
hospitalization, unnecessary investigations, and possibly
long waiting times for appointments;
2. Expand care services across hospital-based and
community-based services with a view to improve and
facilitate earlier access to care, embrace a wider relevant
workforce, and contain costs by attempting to avoid hos-
pitalization, unnecessary investigations, and long waiting
times for specialist appointments;
3. Orchestrate a multidisciplinary approach to care, thereby
offering care tailored to the individual needs of the
person with pain, which is likely to produce the best
possible clinical outcomes. Depending on the complex-
ity of the case, this may include referral to a second-
ary or tertiary hospital for procedures and/or relevant
investigations;
4. Facilitate quicker and early access of persons with spinal
pain to assessment and appropriate care, guided by triage
and diagnosis, so to reduce the duration of morbidity and
attempt to avoid chronicity of pain. Avoiding, or at least
managing, persistent pain would likely have significant
cost savings; and
5. Disseminate information and educate a) the public,
b) consumers, and c) health care professionals regarding
the best practice management of spinal pain.
Care services for the management of persons with pain,
as presented in an MoC or Care Framework document,
would include:
1. Flow charts and diagrams that provide an indication of the
nature and levels of care expected, starting with a triage
process of a person with pain by a vetted, credentialed

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Parkin-Smith et al
health care practitioner, followed by treatment and/or
referral to another care provider or service, and so on;
2. A clear, pragmatic representation of the levels of care
matched with the case complexity, with an explanation
of each level of care;
3. An outline of the consumer’s care journey with informa-
tion on accessibility to care services, relevant organiza-
tions, and self-help material;
4. Rationalize the description care services and the complex
process of care service delivery in an MoC document so
that end users may easily grasp 1) the concept of spinal
pain, and 2) how, who, and where to access the care
services.
For example, uncomplicated cases of persons with spinal
pain may be triaged and managed by the general practitio-
ner or other vetted health care provider in the community,
without the need for referral elsewhere. For more complex
cases, or where preventing the persistence of pain is a prior-
ity, the primary contact health care provider would triage the
“whole” patient and refer to a care service or appropriate
provider – this triage service would include assessment and
determination of the likely level of care needed based on the
complexity of the case. At triage, the consumer would also
receive appropriate information and education about pain, as
this appears to be important in positively changing consum-
ers’ attitudes, expectations, and beliefs.96,97
Workforce capacity and care teams
To offer coordinated multimodal care, health care teams are
recommended, consisting of various disciplines depending
on the level of care an individual person with spinal pain
requires. To determine the level of care needed, the person
with pain would go through a triage process, and, where
necessary, result in a referral to the appropriate health care
provider or multidisciplinary team for further care. This may
include the referral to a secondary or tertiary hospital.
The purpose of creating care teams would be to include
health care disciplines that:
1. Would make a meaningful contribution to the care of
a person with spinal pain, be it via case management,
treatment, or assessment;
2. Facilitate task substitution where various disciplines may
be involved in patient triage, case management, treatment,
and coordination of care;
3. Offer cost-efficient, evidence-based interventions that, as
a package of care, would offer the best possible outcomes
and avoid unnecessary interventions, investigations,
hospital admissions, or duplication of care;
4. Promote early assessment, triage, care, and referral of
persons with pain, with a view to avoid chronicity of
symptoms by offering the right treatment by the right
discipline(s) at the right time.
Care teams would be created through a process of iden-
tifying vetted disciplines that are associated with spinal pain
and/or pain management. In some cases, task substitution
would be feasible where triage and assessment of patients
may be completed by those other than the traditional health
care gatekeeper(s). Appropriate health care practitioners
would be certified to work as part of a multidisciplinary team
with a view to offer coordinated care based on the recom-
mendations of a care framework or MoC. These health care
teams, as part of their involvement in audit and evaluation
of their services, should engage with academics/research-
ers with an interest in pain health, with a view to develop
research projects that examine, explore, and test care services
for spinal pain.
Teamwork cannot be emphasized enough. We acknowl-
edge that, in a competitive health care marketplace, practi-
tioners become protective over their “patch” and become
adversarial when there is a potential threat to their income
and/or professional authority – this is natural. We take this
opportunity to point out that collaboration and teamwork
is likely to generate more business via referrals and ease
of access for consumers. We draw upon observations and
experience from the business management sector, where
developing trusting and collaborative networks or teams
yields better results than adversarial relationships or overt
competition.98
Future direction of research
No doubt, there is an ongoing need to explore the com-
plex nature of pain and pain states, which includes spinal
pain, with a view to gain further insight into appropriate
management. Research efforts should align with health care
needs and, with the principles of evidence-based practice in
mind, should endeavor to inform clinical guidelines, MoC and
policy.47 Future definitive studies, for example prospective
cohort studies or cluster analyses, are more likely to be valu-
able in establishing the effectiveness of multimodal, complex
interventions in specific clinical environments.
We feel that research should, in the context of models or
frameworks of care, be directed toward:
1. The testing of complex interventions, in the form of
care packages, protocols, or combinations of treatment,
using well-designed and piloted clinical trials. This
form of research would test care services, as opposed to

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Spinal pain: a review of care
individual treatments. Outcomes of such research projects
would inform practice and keep clinical guidelines/MoC
up to date;
2. Conducting practice-based cohort studies that gather data
on patient and practice characteristics, so as to gain insight
into the demographics of persons with pain, workforce
capacity, and, possibly, clinical outcomes. Collected data
would inform the need for workforce expansion, emerg-
ing resource requirements, and assist in updating care
service policy alongside providing a clear description of
consumer preference(s);
3. Doing translational and integrative research that facili-
tates the development and testing of mechanisms that
try to get research into practice and policy. Also, such
research will provide insight on how to facilitate the
adherence of health care stakeholders to policy, clinical
guidelines, and MoC. The positive consequence of such
research is likely to be major cost savings and promotion
of best practice;
4. Address the gap in current high-level research, which
tends to exclude the complex patient, especially if they
have associated mental health issues, including anxiety,
stress, and depression, or if they are at the extremes of age
such as children, adolescents, and elder patients (greater
than 65 years of age);
5. Allow exploration of new or refined pain management
techniques, with an active audit process that financially
supports the validation processes; and
6. Prioritize funding for clinical research that has ongoing
cohorts of real patients presenting at the clinical interface
for treatment for significant pain.
In our view, research organizations should continue to
develop research agendas that align with the direction of
research stated above, while simultaneously considering
available research funding opportunities that match those
health care priorities. An example of very informative
and influential research is the long-standing, continuous
cross-sectional Australian BEACH (Bettering the Evalu-
ation And Care of Health) program,99,100 which collects
data on encounters, practitioners, and patients in general
practice. These data have had a tremendous impact on
informing practice and policy. Another example is the
ACORN (Australian Chiropractic Research Network)
project,101 a longitudinal practice-based study, which has
attracted over 1,600 practitioners, with a view to collect
practice and patient data. Such data, alongside those already
collected,102 will serve to describe the various health care
disciplines linked with spinal health and clarify the roles
of these disciplines. Research efforts and data should be
amalgamated or grouped where possible, in the form of
meta-analytical reviews. Again, the proviso in reviewing
grouped data is the negative published bias that can overcall
the effectiveness of an intervention, as the tendency is to
publish positive outcome trials. The clinical trials registers
are enabling protocol registration world-wide and contact
between research groups.103 Grouping research efforts and
data meta-analysis would make outcomes or clinical trials
more generalizable.
A paradox is that current funding for pain research by,
for example, the National Institute of Health (USA) is ,1%
of the overall104 spend on research. This is minimal when
compared to the actual cost of care for pain management.
Strong research leadership is warranted, particularly during
times of cost constraints and tight budgets, because clinical
research can often be viewed as a nonessential expense by
health care administrators and even clinicians,105 where ser-
vice delivery is considered to be of higher priority. Not only
is ongoing research critical for obtaining data on outcomes
and patient/practice characteristics, but it also serves to
inform and improve on guidelines and practice. Therefore,
both ongoing research and the training of talented clinical
researchers will be important in ensuring improvement in
patient care. Creating and maintaining additional clinical
professor positions, would facilitate the tripartite goal of
research, teaching, and integration of research into clinical
practice.
Conclusion
We suggest that there is sufficient understanding of non-
malignant spinal pain to be able to develop and implement
care frameworks or MoC that are based on the principles of
evidence-based practice, matched with available funding
and resources. A multidisciplinary approach tailored to the
individual patient care needs, delivered at an appropriate level
of care by health care teams, is recommended to achieve the
best possible outcomes, improve on patient satisfaction with
care, and be cost efficient. Leadership, ongoing research and
continuing advancement of MoC is needed to improve the
care services for spinal pain.
Disclosure
The authors report no conflicts of interest in this work.
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