Guidelines for the management of mechanical low back pain
have robustly stated that 90% of patients recover in 6 weeks. However, new knowledge is emerging that gives a more complete and somewhat less optimistic picture. A meta-analysis published online in the Canadian Medical Association Journal 1,2 analysed data on over 11,000 patients from 33 inception cohort studies looking at the clinical course of low back pain. Studies of patients with acute (<12 weeks) and ‘persistent’ (12–52 weeks) low back pain reporting pain and disability were included in the analysis. The study found that although there is indeed rapid early improvement of symptoms, in rather too many patients symptoms and a degree of disability are still troublesome up to a year after the onset of symptoms. Pain and disability were found to be more troublesome in patients with ‘persistent’ pain. In an online interview one of the authors suggested that low back pain should be viewed as a long-term condition such as asthma and diabetes where lifelong self-management is required and healthy lifestyle choices are the key to success. The conclusion also emphasised the need for clinicians to identify factors leading to chronicity. 3 So how do primary care clinicians identify high-risk patients?
This brings us nicely to the Keele STarT Back tool (advertised in Synovium 35) which has been shown to do just that. This tool was designed to screen primary care patients with low back pain and stratify them into low-, medium- and high-risk categories. The tool was validated in 2008.
It is a simple 9-item questionnaire completed by the patient. The questions concern pain referred to the leg, co-morbid pain, disability (2 items), bothersomeness, catastrophising, fear, anxiety and depression. Patients scoring highly on the last 5 items (the psychosocial subscale) are considered high risk for chronic back pain. 4 So what next?
Use of the tool showed that targeting patients at high risk for chronic back pain with specific interventions can lead to better outcomes. A more recent Arthritis Research UK-funded study from Keele
has shown that stratified care based on the level of risk identified has both clinical and economic benefits. Patients were assessed using the STarT Back screening tool and then randomised to either stratified care or standard back pain care. In the stratified-care group low-risk patients received just 1 session of advice from a physiotherapist; medium-risk patients received the advice plus physiotherapy targeted at symptoms and improving function; and high-risk patients received the advice plus ‘psychologically informed physiotherapy’, which addressed symptoms, function and psychosocial obstacles to recovery. Stratified care was associated with reduced disability scores in the medium- and high-risk groups compared to standard care. Low-risk patients randomised to stratified care also did at least as well with just 1 session of advice compared to low-risk patients referred to standard care who received an average of 5 physiotherapy sessions. Overall the costs of care in the stratified-care group were lower than for standard care because the extra costs of the psychologically orientated care for high-risk patients were exceeded by the savings made on low-risk patients. In these austere times it is heartening to know that improved care can be achieved at the same time as cost improvements. 5