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How STarTBack is reducing pain levels

Published on 29 September 2011

Shaking up the way that people with back pain are managed in primary care so they are given more targeted treatment makes a “significant difference” to patients’ levels of pain and distress, according to new research published in The Lancet.

The Arthritis Research UK-funded study involving more than 850 back pain sufferers found that a more targeted approach to physiotherapy, which is more reflective of patients’ individual needs, helps people with back pain take less time off work. And patients themselves were more satisfied with their care.

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.

Professor Elaine HayChief investigator and director of the Arthritis Research UK Primary Care Centre at Keele University, Professor Elaine Hay, said: “Importantly, we also found that this new targeted approach substantially reduced healthcare costs and therefore has important implications for commissioners and providers of back pain services.”

Medical director of Arthritis Research UK, Professor Alan Silman, added: “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.”

NHS Direct in Scotland have already decided to use the targeted approach and it is being used across NHS services in the UK and a number of other countries to form the basis for new health care systems being developed.

“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. “The data shows that it is having a substantial beneficial impact where it is being implemented, making a big difference to patients.”

Back pain is very common, and 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. The STartTBack model doesn’t assume that ‘one size fits all’ and as such allows clinicians to ensure treatments are targeted to the right patient.

“The problem for GPs and other health professionals is spotting who, amongst the patients they see with back pain, is likely to get better with simple advice and reassurance, and who might benefit from further treatment from a physiotherapist,” added Professor Hay.

The approach trialled in The Lancet study used a new questionnaire (the Keele STarTBack screening tool) to assess whether patients were at low, medium or high risk of having persistent, disabling symptoms from their back pain. Using the tool, 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, 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.

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.

The study found that the StarTBack approach changed the pattern of physiotherapy referral in a way that was more responsive to people’s needs, resulting in a significantly improved levels of pain and distress, helped them take less time off work, cost less than the best current care, and led to more patient satisfaction.

The STarTBack website which informs clinicians about the new approach is getting 500 visitors per month from around the world, and a short documentary video about the approach is currently being made available via the internet. The research group at Keele has run training courses to help clinicians gain the appropriate skills to implement the approach in their practice and will consider running further courses if required.

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