Transforming back pain care-why, what, and how?

The IASP has designated 2021 as Global Year Against Back Pain, a choice that no one reading this month’s Topical Review could dispute, reinforced by updated burden-ofdisease estimates for low back pain (LBP). Yet, LBP remains an elephant-in-the-room for clinicians practicing in biomedical approaches to illness and disease, and for their professional organisations and industry partners who must listen to evidence that surgery, drugs, and injections on the whole do more harm than good beyond narrowly drawn boundaries. But the clamour for change gets louder. “Calls-for-action” in the world press and leading medical and public health journals argue for a global shift in LBP care, away from low-value interventions that deliver ineffective, costly, or potentially harmful outcomes, towards high-value care that is effective, affordable, and safe. To promote high-value care and shift patients’ expectations and participation in their own care, action is needed at multiple levels—in health and social care systems supported by policy and regulation (eg, “governments and insurers need to start paying for the right things”), in health services (eg, “redesign clinical pathways to deliver high-value care”), and in practice (eg, “evidence does not support the use of gabapentinoids for nonspecific LBP”). Drawing on a wide body of evidence for their Topical Review, George et al. present a framework for action at one of these levels—service delivery—in one healthcare system (America). They importantly incorporate “population-based resources for selfmanagement” (ie, public health interventions to reduce unnecessary healthcare demand and promote back health) and transdisciplinary “foundational back pain care,” as well as strategies to ensure specialised care is delivered only to those likely to benefit. Their proposal is timely, given America’s combustible mix of opioid epidemic, unsustainable expenditure on musculoskeletal health services, and consumer-orientated promotion of low-value interventions. It emphasises the positive—what needs to be done—as well as highlighting what must be discontinued. Illustrated with examples of local adaptations of service models delivering change, the framework appears fit-for-purpose for the American context, and, if widely adopted there, would answer the call for redesigned pathways to deliver high-value care. But the questions raised by the Review, particularly for research priorities and the transferability of its proposals to settings outside America, are as important as the solutions it offers. For the research agenda, 2 questions hang over guideline-driven LBP care pathways. First, are there better treatments for patients with LBP once low-value care has been abandoned and positive strategies of exercise and rehabilitation adopted? Most guidelinerecommended treatments have small effect sizes but are attractive because they avoid the potential harms of low-value alternatives and are often more cost effective. Fresh perspectives, such as more thoughtful consideration of the complexity of LBP experience, must fuel the search for efficaciousnew interventions (includingnovel components of care and innovative means of delivering them), while the necessary task of identifying low-value care continues. Second, can transformations in service delivery, such asproposedbyGeorge et al., be implementedand sustained in complex anddynamic health systems, and do they reduce the years-lived-with-disability in populations? Long-termoutcomes research, enabledby responsive health information systems, must answer such questions. From a global perspective, the question is whether the Review’s proposals can be shaped for contexts very different to America, or whether healthcare systems at different stages of maturity must develop their own service models. The components of evidencebased care (the “what-to-do”) are likely to applywidely, including in lowand middle-income countries (LMICs). Primary care providers of LBP care in LMICs, for example, use the same biomedical language and passive approaches to treatment that are targets for change in high-income countries, while purveyors of imaging and surgical technology and drugs have a global reach. However, mechanisms of delivery (the “how-to-doit”) will vary. Critically, local adaptation in LMICs must articulate with indigenous health systems and support task-sharing across workforce cadres, such as community workers, relevant to those countries. But, in moving from “what-to-do” to “how-to-do-it,” the broader question is whether service-level transformation candeliver sustainable high-value LBP care without system-level change. The answer is almost certainly “no.” Innovative service models are rarely sustained in environments with inadequate resourcing, counterproductive economic and promotional pressures, inflexible funding models, defunct policy frameworks, health information systems that do not routinely capture relevant patient-reported information and outcomes, and an inappropriately trained workforce. George et al.’s service-level framework for change acknowledges this, but the logical implication is that service redesign will only succeed if other levels are transformed too. Globally, there is evidence that such system-level change is possible and is happening slowly. Transformative initiatives at this level are occurring internationally in LBP and musculoskeletal care, and global efforts are strengthening health systems in ageing and rehabilitation. But, the assumptions underpinning the Review’s framework are often absent or inadequate in lowerresourced settings. Even in high middle-income countries such as South Africa, health system frailty (inequality of access, poor continuity of care, lack of multidisciplinary teams and approaches, workforce shortages, and bias towards a curative Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. a School of Primary, Community and Social Care, Keele University, Keele, United Kingdom, b Physiotherapy Division, Department of Health and Rehabilitation Sciences, Stellenbosch University, South Africa, c School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia