Anne Moseley talked to Dr Jonathan Hill (Keele University, UK) whose trial evaluating stratified primary care management for low back pain is one of the 15 most significant trials in physiotherapy.
Anne: Explain what you did in the study
Jonathan: The STarT Back trial was designed to compare the clinical and cost effectiveness of stratified management of low back pain; allocating patients to targeted treatment pathways based on their screened prognostic risk category (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, UK, and was funded by a patient charity called 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.
Anne: What was the main finding?
Jonathan: 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 pain, 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.
Anne: Why do you think the study is important?
Jonathan: The STarT Back trial was the first study to test a stratified care approach for the management of back pain in primary care, and published in The Lancet, has been ground breaking in providing a simple and practical model for improving the effectiveness and costs of care compared to conventional pathways. Stratified care also enables clinicians to deliver more tailored services for patients with back pain and has challenged the existing one-size-fits-all and stepped care models suggested in current guidelines.
Anne: What lead you to do the study?
Jonathan: Around 9% of adults in the UK visit their general practitioner about back pain every year, but as many as 80% of these patients still report pain or disability a year after first consulting. Although trials have reported the benefits of a wide range of treatments such as exercise, manual therapies 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 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.
Anne: What studies are you conducting now?
Jonathan: Replication clinical trials of the STarT Back approach are currently being conducted in Seattle USA, led by Professor Dan Cherkin and separately by a Danish trial team led by Dr Lars Morsoe. The Keele team are currently undertaking research using a large clinical trial to test if a stratified care approach can be extended (using a combination of prognosis and clinical signs) for patients with sciatica presenting to primary care, including identifying which patients may need a fast-track pathway to receive a surgical opinion. A separate programme of research is also testing a new stratified care approach for patients with the 5 most common musculoskeletal conditions presenting to primary care including back, neck, shoulder, knee, and multi-site pain.
Anne: Jonathan, thank you for making such a valuable contribution to physiotherapy.
You can find out more about STarT Back from these videos: