Back pain: A new approach

29th September 2011 - Every year, around 9% of adults in the UK visit their GP about back pain, but the existing one-size-fits-all treatment could be improved upon according to the results of a new trial.
The STarT Back trial, which includes a simple screening questionnaire for patients, was carried out at the Arthritis Research UK Primary Care Centre, Keele University, Stoke-on-Trent and was funded by Arthritis Research UK.

Medical director of Arthritis Research UK, Professor Alan Silman, said via e-mail: "Improving the outlook for patients with back pain has been the subject of an enormous amount of research over several years, with exercise and psychological approaches being trialled. This research is novel because it shows how to take the best of these two approaches, and make a real difference to large numbers of patients."

A new approach

The study, published Online First in The Lancet, looked at a stratified approach to the management of low back pain in primary care, giving GP's more information.
Stratified care involves a tailored approach to the management of back pain that challenges the existing one-size-fits-all primary care strategy suggested in current guidelines whereby GPs decide who can self manage their back pain and who needs extra care.
Although previous  trials have reported the benefits of a wide range of treatments such as exercise and cognitive behavioural approaches compared with standard care, a lack of evidence about which patients are likely to benefit from which interventions has reduced the efficiency of primary care management.

The STarT Back trial was designed to compare the clinical and cost effectiveness of stratified management-allocating patients to different treatment pathways based on their prognosis (low, medium, or high risk of poor outcome)-with that of current best practice.

STarT Back trial

The investigators recruited 851 adults with back pain between June 2007, and November 2008, from ten general practices in England. Patients were randomly assigned to stratified care or current best practice of advice, exercise and manual therapy delivered by physiotherapists.

Those undergoing stratified care were asked to complete a simple, nine question, screening questionnaire to allocate them into three groups: low, medium, or high risk. They then received treatment specifically tailored to their needs.

At both four months and 12 months, patients in the intervention group showed a significant improvement in disability scores compared with patients in the control group.

Additionally, at 12 months the intervention group were more likely to report reduced fear, less depression, and better general health.

Patients given the stratified care intervention were also significantly more likely to be satisfied with their treatment compared with current best care at four months, and took fewer days off work because of back pain over the 12 month study period.

The stratified management intervention also resulted in a greater health benefit that was achieved at a lower average health-care cost, an average saving of £34.39 per patient.