New approach to management of back pain reduces disability and is cheaper

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Posted on 29 September 2011
“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."

A stratified approach* to the management of back pain in primary care could provide a more effective and cheaper alternative to conventional care, suggests the first study to test the new model, published Online First in The Lancet. 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, which leave as many as 80% of people still reporting pain or disability a year after consulting their general practitioner.

Around 9% of adults in the UK visit their general practitioner about back pain every year. Although 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. The trial was carried out at the Arthritis Research UK Primary Care Centre, Keele University, Stoke-on-Trent, UK, and was funded by Arthritis Research UK.

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*** (intervention group; 568) or current best practice of advice, exercise and manual therapy delivered by physiotherapists (control group; 283).

The Roland and Morris Disability Questionnaire was used to measure whether the treatments helped relieve back pain and improved patients’ ability to function. The researchers also estimated the cost effectiveness of the two strategies in terms of quality adjusted life years (QALYS) and health-care costs.

At both 4 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 4 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.

The authors say: “For many years, the potential for targeting treatment has been emphasised as a research priority for back pain. The results of this trial provide the first evidence that a stratified management approach to target the provision of primary care significantly improves patient outcomes and is associated with substantial economic benefits compared with current best practice.”

They conclude: “The findings of this study represent an important advance in primary care management of back pain, and have important implications for commissioners and providers of services for back pain.”

Chief investigator and director of the Arthritis Research UK Primary Care Centre at Keele University, Professor Elaine Hay, said: “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.

“Equally 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 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 STarT Back 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.”

In a Comment, Bart Koes from Erasmus University Medical Centre, Rotterdam, The Netherlands remarks: “These results are indeed very promising…The economic assessment showed the new approach was cost-effective so there is no financial reason not to implement the new intervention…Clinicians and researchers now face the challenge of implementing and further optimising the new approach.”


Dr Jonathan Hill, Keele University, Keele, UK.  T) +44 (0)1782 733900  E)

Alternative contact: Chris Stone, Press Office, Keele University. T) +44 (0) 1782 733375 E)

Dr Bart Koes, Erasmus University Medical Centre, Rotterdam, The Netherlands.

T) +31 10 7043 620 E)


Notes to Editors:

*The stratified model uses a simple screening questionnaire to allocate people with low back pain to three groups based on their estimated risk of persistent disability (low, medium, or high risk). Treatment interventions are then tailored to each of these groups to improve outcomes.

***People categorised as low risk were given a minimum of one session involving advice on activity, exercise, and returning to work. The medium-risk group were also referred for standardised physiotherapy, and the high-risk group to psychologically informed physiotherapy.