Background

Internet delivered interventions may provide a route to rapid support for behavioural self-management for low back pain (LBP) that could be widely applied within primary care. Although evidence is emerging that more complex technologies (mobile apps linked to digital wristbands) can have some impact on LBP-related disability, there is a need to determine the effectiveness of highly accessible, web-based support for self-management for LBP.

Background

Low back-related leg pain (LBLP) is clinically diagnosed as referred leg pain or sciatica. Within the spectrum of LBLP there may be unrecognised subgroups of patients. This study aimed to identify and describe clusters of LBLP patients using latent class analysis (LCA).

Introduction

Early intervention is advocated to prevent long-term work absence due to musculoskeletal (MSK) pain. The SWAP trial tested whether adding a vocational advice (VA) service to best current care led to fewer days work absence over 4 months.

Background:

Internet interventions provide an opportunity to encourage patients with LBP to self-manage and remain active, by tailoring advice and providing evidence-based support for increasing physical activity. This paper reports the development of the ‘SupportBack’ internet intervention, designed for use with usual primary care, as the first stage of a feasibility RCT currently underway comparing: usual primary care alone; usual care plus the internet intervention; usual care plus the internet intervention with physiotherapist telephone support.

Background:

Identification of nerve root involvement (NRI) in patients with low back-related leg pain (LBLP) can be challenging. Diagnostic models have mainly been developed in secondary care with conflicting reference standards and predictor selection. This study aims to ascertain which cluster of items from clinical assessment best identify NRI in primary care consulters with LBLP

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

60% of back pain patients report pain radiation in the leg(s), which is associated with worse symptoms and poorer recovery. The majority are treated in primary care, but detailed information about them is scarce. The objective of this study is to describe the characteristics of patients with back and leg pain-seeking treatment in primary care.

Background

Pain with radiation to the leg is a common presentation in back pain patients. Radiating leg pain is either referred pain or radicular, commonly described as sciatica. Clinically distinguishing between these types of leg pain is recognized as difficult but important for management purposes. The aim of this study was to investigate inter-therapist agreement when diagnosing referred or radicular pain.

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.

Background

One untested back pain treatment model is to stratify management depending on prognosis (low, medium or high-risk). This 2-arm RCT investigated: (i) overall clinical and cost-effectiveness of stratified primary care (intervention), versus non-stratified current best practice (control); and (ii) whether low-risk patients had non-inferior outcomes, and medium/high-risk groups had superior outcomes.

Purpose and background

Research on people's own experiences of living with sciatica is limited and this study aims to contribute to a better understanding of the impact of sciatica and its treatment.

Purpose and background

Although low back pain (LBP) with leg pain, is considered by most a poor prognostic indicator, it is at the same time believed to have a favourable natural resolution, and is often treated along similar lines to non-specific LBP, in line with current guidelines. It is unclear whether patients with LBP and leg pain are a distinct subgroup that might benefit from early identification and targeted interventions. We set out to investigate the impact of LBP with leg pain on health outcomes and health resources compared with that of LBP alone, and to explore which factors contribute to the observed disability outcomes.

Objectives: To assess the evidence for a similar pattern of response to treatment among non-specific low back pain (NSLBP) patients in clinical trials.

Design: A systematic review of published trials on NSLBP and meta-analysis of within-group treatment effect calculated as the Standardised Mean Difference (SMD).

Data source: The Cochrane Register of Controlled Trials’ database (CENTRAL), April 2007.

Review methods: We included randomised controlled trials that investigated the effectiveness of primary care treatments in patients with NSLBP aged 18 years or over. We excluded trials conducted in patients with LBP of identifiable cause (e.g. disc herniation or arthritis), post-operative or post-traumatic back pain, or back pain during pregnancy or labour. We chose outcome measures commonly used in the majority of NSLBP trials, namely the Visual Analogue scale (VAS) for pain severity, Roland Morris Disability questionnaire (RMDQ) and Oswestry Disability questionnaire (ODQ) for physical functioning.

Results: 118 trials investigating a wide range of primary care treatment for NSLBP were included. In spite of heterogeneity, we found evidence for a similar pattern of symptom improvement represented by large SMDs at six weeks follow up ((0.86 for pain, 95% CI = 0.65,1.07, 0.97 for RMDQ, 95% CI = 0.66,1.28 and 0.98 for ODQ, 95% CI = 0.62,1.33) followed by much smaller further change at 13 week (pain 1.07 95% CI = 0.87,1.27, RMDQ 0.93 95% CI = 0.67,1.20, ODQ 0.92 95% CI = 0.70,1.14), 27 week (pain 1.03 95% CI = 0.82,1.25, RMDQ 0.91 95% CI = 0.59,1.24, ODQ 1.08 95% CI = 0.80,1.36 and 52 week (pain 0.88 95% CI = 0.60,1.1, RMDQ 1.01 95% CI = 0.68,1.34, ODQ 1.14 95% CI = 0.88,1.39). There was no statistically significant difference between responses in various trials arms (index treatment, active comparator treatment, placebo or sham treatment, usual care or waiting list controls). There was also no statistically significant difference between responses to pharmacological and non-pharmacological treatments.

Conclusions: NSLBP symptoms seem to improve very well and in a similar pattern in clinical trials following a wide variety of active as well as inactive treatments. It is important to explore factors other than the treatments themselves that might influence symptom improvement. Exploring possible sources of underlying heterogeneity in responses might lead to some of these factors.

Conflict of Interest: None

Source of Funding: This work is part of a PhD fellowship funded by the arc (Arthritis research campaign).

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.

Introduction: Detecting relevant clinical subgroups of patients with non-specific LBP is a priority for research as it has potential for improving treatment effectiveness. The STarT Back Tool (SBT) was recently developed and validated to subgroup LBP patients into targeted treatment pathways in primary care. This study tested the SBT’s criterion validity against a popular existing LBP subgrouping tool – the Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ).

Methods: 244 consecutive ‘non-specific’ LBP consulters at 8 GP practices aged 18–59 years were invited to complete a questionnaire. Measures included the OMPSQ & SBT; disability (RMDQ); pain intensity (11-item NRS); duration of symptoms; and demographics. Instruments were compared using Spearman’s rank correlation, discriminant analysis of subgroups, tests for allocation agreement and predictive validity using published data.

Results: Completed SBT (9-items) and OMPSQ (24-items) data was available for 130/244 patients (53%). The correlation of SBT and OMPSQ scores was ‘excellent (rs = 0.80, p=< 0.001). Subgroup characteristics from both tools were similar particularly among the ‘low’ risk groups, however, the proportion of patients allocated to ‘low’, ‘medium’ and ‘high’ risk groups were different, with more distressed patients in the SBT’s high risk group. The SBT better predicted pain and disability at 6 months and both equally predicted time off work.

Conclusion: The SBT psychometric properties perform as well or better than the OMPSQ, but the SBT is shorter and easier to score. It is therefore an appropriate alternative for screening LBP patients in primary care.

Introduction: Previous studies have shown that advice given to patients with low back pain (LBP) by health care practitioners (HCPs) such as physiotherapists (PTs) and general practitioners (GPs) is not in line with guidelines about encouraging early return to work. The aim of this study was to describe the attitudes, beliefs and reported practice behaviour of UK GPs and PTs about LBP and to explore associations between these.

Methods: A national cross-sectional survey of GPs and PTs (n=4000), including an attitudes measure, the Pain Attitudes and Beliefs Scale (PABS.PT), which measures ‘biomedical and behavioural orientations of HCPs. A vignette describing a patient with non-specific LBP, who had a four-week absence from work, was used to capture reported clinical management. This presentation will focus on the findings about work advice.

Results: Response rates were 22% (n=446) for GPs and 55% (n=1091) for PTs. Almost one third of GPs (32%) and one in four PTs (25%) reported that they would advise the vignette patient to remain off work. The HCPs advising the vignette patient to remain off work had significantly higher biomedical (F_1,988=78.85, p< 0.001) and lower behavioural (F_1,981=31.89, p< 0.001) scores on the PABS.PT than those suggesting a return to work.

Conclusion: An association between attitudes and reported practice behaviour was apparent, with HCPs operating within a predominantly biomedical framework being more likely to advise a patient with back pain to stay off work. Further research should explore how HCPs’ attitudes might be changed and whether this results in changes in work recommendations.

Background: Last year we presented the STarT Back Tool, which is validated for use in Primary Care. It subgroups patients into 3 categories (high, medium and low risk) on the basis of modifiable risk factors for chronicity. We are now piloting the feasibility of using the tool as part of a new approach to sub-grouping and targeting back pain in primary care.

Methods: The physiotherapy interventions for the 3 subgroups were developed after reviewing the literature, current guidelines, the content of existing targeted treatment programmes, and convening workshops with internationally recognised experts. Both the intervention training modules, and the targeted treatments were piloted. Consecutive back pain consulters were identified using GP electronic Read Codes (weekly downloads) and invited to attend the study’s back pain clinic. Consenting patients completed a baseline questionnaire and were classified by the tool into one of 3 sub-groups.

Results: 60 patients were recruited. 50 patients were allocated to receive treatment according to their subgroup allocation and 10 patients (control group) received a triage physiotherapy assessment (usual care) to decide if they needed further physiotherapy treatment. Primary outcomes include the Roland Morris Disability Questionnaire and the Pain Catastrophising Scale. Three-month follow-up postal questionnaires are currently being administered and outcomes will be presented at the conference. Clinicians involved (GPs, and physiotherapists) will be interviewed to identify the feasibility of this approach.

Conclusions: Once feasibility is established we will take this developmental work forwards into the clinical trial arena to investigate whether this novel “sub-grouping for targeted treatment” approach provides a cost effective way of reducing long-term risk of chronic disability in patients consulting their GP with back pain.

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.