Purpose and background

To explore the cost-utility of implementing stratified care for low back pain (LBP) in general practice, compared with usual care, within patient risk subgroups (low, medium and high risk of persistent disabling pain determined by the STarT Back tool).

Background and purpose

The STarT Back trial demonstrated benefits from a stratified primary care model that targets low back pain (LBP) treatment according to patient prognosis (low-, medium-, or high-risk). The current IMPaCT Back study implemented this approach in everyday primary care to investigate; i) changes in GPs' and physiotherapists' attitudes, confidence and behaviours, ii) patients' clinical outcomes, and iii) cost-effectiveness.

Purpose of the study: The aim of this study was to develop an individualised assessment tool capable of defining clinically meaningful change within areas identified by each patient as important.

Background: Much work has been dedicated to identifying a definition of successful outcome in LBP. However, what is important to the patient is often not considered, or is poorly assessed. Goals that are important to the individual enhance self-engagement, and can serve as strong motivators of action in rehabilitation. Goal Scaling is a method which enables patients to systematically identify individualised goals, to quantify their achievement, and may provide a valid outcome of genuine importance to the patient.

Methods: A semi-structured interview was developed around the principles of goal attainment scaling, but modified to elicit patient identified individualised goals that incorporate a marker of “minimum important change” within each scale. Patients also completed measures on disability and global change in condition, and were followed-up for six months.

Results: Thirty-five patients referred to a specialised LBP clinic took part in this pilot study. Patients were able to identify specific realistic goals, and understood the concept of minimal important change within their chosen goal areas. At six months, goal attainment scores were responsive to change, associated with disability and global change in condition, and able to distinguish between “improvers” and “non-improvers”.

Conclusion: Goal scaling provided useful additional information about the problems associated with, and the progress of patients with LBP. Work on a self-complete version for use in clinical trials is underway.

Background: Patients with LBP, ‘at risk’ of persistent symptoms, require targeted treatment in primary care. We have therefore developed and validated a new screening tool to classify these patients into appropriate management groups.

Methods: A list of LBP prognostic indicators was compiled by reviewing published studies and analysing existing datasets. Indicators were selected for the tool according to face and construct validity, consistency and strength of association. For each indicator outcome measure (e.g. Pain Catastrophising Scale) an individual question (e.g. ‘I feel that my back pain is terrible and that it is never going to get an better’) was selected for inclusion (ROC analysis). The tool was modelled to classify patients into 3 categories of risk. The screening tool and corresponding complete scales were mailed to 244 consecutive primary care LBP consulters. Individual items were validated against complete scales. Reliability was examined on 53 responders.

Results: This new screening tool classifies patients using 9-items to cover 8 key prognostic indicators. The questionnaires returned by 131 consulters demonstrated excellent construct validity for all individual items. 33% of patients were classified as ‘high risk’ (psychosocial and physical factors), 44% ‘intermediate risk’ (physical factors alone) and 23% ‘low risk’. Discrimination between groups across relevant constructs such as pain, disability, days off work and psychological distress was highly significant. Test-retest reliability was moderate (kappa = 0.54).

Conclusions: A novel LBP screening tool has been validated in primary care and effectively classifies patients ‘at risk’ of persistent symptoms. This will facilitate appropriate targeting of treatment.

Purpose of the study: To investigate whether video analysis, in addition to self-reported paper audit, could elucidate expected differences in the content of two interventions.

Background: We have completed a randomised clinical trial comparing two types of physiotherapy for subacute low back pain (“hands on” physiotherapy versus a pain management programme). An essential component in conducting clinical trials is to audit the interventions to check for compliance with the protocol. We use two approached:

self complete proforma

Methods: i) Treatment content was recorded on a proforma by the physiotherapists after each session.

ii) A check-list of treatment modalities was constructed from this proforma. Twelve sessions were recorded on video (one new and one review patient for each therapist). The recordings were rated by 3 blinded, independent observers using the checklist. These were compared with the self-report audit forms relating to the same physiotherapy session.

Results: Analysis of the videos showed good levels of agreement (67%) between the 3 observers. Agreement between the video content and paper audit was also good (84%, _ = 0.59). The complete paper audit revealed clear differences between the treatment arms. Patients undergoing the “handson” treatment received manual therapy, whereas patients in the pain management group had specific issues addressed in the course of the consultation.

Conclusions: Feasible, reliable methods of confirming the content of interventions delivered in pragmatic trials are difficult to achieve. Self report paper audits are simple but rely upon the honesty and accuracy of the completer, and may not pick up subtle differences in approach. Video recording is time consuming, may be threatening to the treating practitioner and patient, and is difficult to analyse. A compromise approach involving sample video recordings along with paper self complete audit was able to validate the content of the treatments delivered.

Purpose of the study: The aim of this ongoing research is to develop and utilise an individualised, patient-centred approach to outcome measurement in LBP. Specifically, we aim to develop an assessment tool capable of defining “clinically meaningful change” within each patient.

Background: Much work has been dedicated to identifying a definition of successful outcome in LBP. A consensus meeting suggested that 5 discrete domains merit measurement (back specific function, generic health status, pain, work disability and patient satisfaction). Validated tools exist which measure each of these domains. However, how to define what constitutes a “clinically meaningful improvement” as distinct from a “statistically significant change” remains problematic.

Patient satisfaction has been identified as a key dimension in the assessment of outcome in LBP. However what outcome is important to the patient is often not considered, or is poorly assessed. Goal Attainment Scaling (GAS) is a method for systematically targeting individualised goals, and quantifying their achievement. This will provide a valid outcome measure of genuine importance to the patient.

Methods: A semi-structured interview is being developed around the principles of GAS, but specifically modified to elicit patient identified individualised goals that incorporate a marker of “minimum important change” within each scale.

Results: Pilot work has shown that patients can identify meaningful individual goals, which will serve as individualised outcome measures. Furthermore, the notion of achieving a “minimum important change” based around these concepts and within these target scales appears to be generally understood.

Conclusions: Development of an individualised assessment tool capable of defining “clinically meaningful change” within each patient is ongoing. Future work will focus on identifying associations between this individualised outcome and other widely used measures in LBP research, and in establishing the clinical practicality of this approach for use in treatment trials.