Back to fitness
Published on 05 January 2012
A new questionnaire that takes just 30 seconds to fill in is having a big impact on the way people with low back pain are treated. Jane Tadman reports.
With the average GP consultation running to just 10 minutes, there’s not much time for family doctors to get to the bottom of a patient’s back pain. Back pain is not just extremely common, but also complicated. What for some people might be a short-lived if painful affair can become chronic (long-lasting) in others.
Current guidelines for GPs highlight the need to give good advice to patients about taking painkillers, avoiding bed-rest and continuing their daily activities, including staying at work. For most patients that is sufficient. However, some people don’t recover so quickly and might need referral to a physiotherapist for exercise or manual therapy, while others may need their fears and anxieties about their pain, motivation, mood and work situation addressing. When back pain doesn’t clear up, and treatment doesn’t seem to help, sufferers can quickly become de-conditioned and spiral into depression and immobility, some losing their jobs and their self-confidence along the way.
“The problem for GPs and other health professionals is spotting who, amongst the patients they see with non-specific back pain, is likely to get better with simple advice and reassurance, and who might benefit from further treatment from a physiotherapist,” explains Professor Elaine Hay, director of the Arthritis Research UK Primary Care Centre at Keele University.
In response to this, researchers led by Professor Hay have developed a new screening tool, the Keele STarTBack Tool. This is a nine-question questionnaire given to patients during their GP consultation that takes between 30 seconds and a minute to complete, which has been developed as part of a clinical trial funded by Arthritis Research UK. The questions in the screening tool have been designed to pick up whether a patient’s risk of back pain becoming chronic is low, medium or high.
This in turn leads to them being offered different treatments with those at highest risk of their back pain becoming chronic given the most intensive physiotherapy treatment, while those at low risk are encouraged to avoid numerous sessions of treatment that are unlikely to be beneficial.
The results of the study, published in The Lancet, clearly demonstrate that this new approach can have a major effect. Not only does this ‘screening for targeted treatment’ approach make a significant difference to people’s pain and disability levels, it has also been shown to save the NHS money.
What this means is that a stratified or targeted approach to managing back pain in primary care is effective, and challenges the ‘one-size fits all’ strategy that is currently recommended by national guidelines in which everyone with nonspecific back pain (ie excluding those patients with potentially serious causes of their back pain) is offered the same treatment, irrespective of their risk of persistent problems.
“Effectively we found that a more systematic approach to targeting treatment changed the pattern of physiotherapy referral in a way that was more responsive to people’s needs,” says study leader Dr Jonathan Hill. “This resulted in significantly improved levels of pain and distress for patients, helped them take less time off work and led to more patient satisfaction.”
Professor Hay adds: “Importantly, we found that this new targeted approach substantially reduced healthcare costs and therefore has important implications for commissioners and providers of back pain services.”
Already the STarTBack approach is being widely used. “The new STarTBack screening tool we have developed is already proving popular in the UK, with 50 centres adopting it, and also internationally,” added Professor Hay.
Dr Ollie Hart, a GP with a special interest in chronic pain, and the GP commissioning lead in musculoskeletal conditions in Sheffield, has been using the STarTback approach to back pain in his practice for the past year and is a big supporter. Since November all GPs in Sheffield have been using the tool.
“The approach has to work in the real world,” he says. “When people are seen by their GP they need to be effectively triaged, so they are sent to different types of physiotherapists. That means people considered to be at high risk of having chronic back pain get to see a very experienced physiotherapist; perhaps an extended scope practitioner who can offer a more complex psychological approach. It’s a challenge for all health professionals to manage this but we need to get into the habit of using the tool.”
Dr Hart, who has a long-term interest in back pain, says it is important, in these cash-strapped times, that STarTBack approach was shown to be cost-effective. “I’ve seen so many people with back pain who have been poorly managed early on and you feel like tearing your hair out when you see them,” he says. The most important thing is to get appropriate care early on. If you deal with back pain properly up front then it will be cheaper and there will be fewer costs down the line – otherwise people have to take time off work, require more intensive treatment later on, and so on.”
The beauty of the STarTback tool, believes Dr Hart, is its simplicity. “It’s a short questionnaire and takes between 30 seconds and one minute. It’s fantastic that something so simple could have such a big effect. It’s practical to use.”
Dr Hart acknowledges that back pain is his specialty and other GPs might not share his enthusiasm. “I’m interested in back pain and in the screening tool and have made an effort to do it. Will other GPs who are not interested use it too? That’s the crucial thing. What motivates GPs is something that they think will make a difference.”
Margaret Robertson, now 77, took part in the STarTBack trial, and found the exercises she was given by her physiotherapist ‘saved her life’ when she developed painful sciatica. She did stretching and strengthening exercises four times a day and found they were much more effective than painkillers. She still does them after three years and has not had to take painkillers since.
John Allen, a retired solicitor, aged 71, suffered from sciatica in his legs and had back spasms when he joined STarTBack. He did the exercises every day for a week and the pain gradually subsided. He does a lot of heavy DIY and gardening and still has night-time backache, although the exercises keep it at bay.
What did the trial show?
The STarTBack approach was compared with current best physiotherapy care, where decisions about who to refer on for more intensive physiotherapy were at the discretion of the clinician and were not informed by the tool score.
In the trial 851 people were allocated to targeted treatment (the STarTBack approach) or to current best physiotherapy care. Those allocated to the STarTBack approach were divided into three groups based on their tool score, and each group was matched to specially tailored treatment. Patients in the low risk group received a good package of advice about how to manage their back pain in a single session with a physiotherapist, while patients in the medium and high risk groups were referred for more intensive physiotherapy treatment. High risk patients were seen by physiotherapists who had received extra training about how to address psychological problems, which can often be associated with chronic back pain.
Crucially, those patients at highest risk of their back pain becoming long-term – because they are afraid that exercise will make it worse, for example - benefited from a more intensive approach that addressed their specific worries.