Objectives: 80% of people report low back pain (LBP) over their life time. Chronic LBP is recognised as a significant cost burden for society. NICE Guidelines (NICE, 2016) support the use of risk stratification in this population to facilitate targeted treatment approaches. The use of group interventions combining both education and exercise is also widely supported (Pillastrini et al, 2012). In Dublin South-West (DSW), back pain referrals make up 25% of all referrals to Primary Care Physiotherapy. This initiative, run throughout 2016, aimed to deliver effective and efficient targeted treatment using a stratified care pathway, while promoting self-management in this population.
Methods: 79 patients referred to Primary Care Physiotherapy with LBP were triaged by 3 senior-level physiotherapists. Patients were screened using a specially-developed assessment form to ensure standardisation. Patients were screened for red flags, then classified as having either serious spinal pathology, specific spinal causes of pain, or non-specific LBP (NSLBP), before being stratified into one of four care pathways: 1. advice and discharge 2. group intervention 3. 1:1 intervention 4. onward referral. Outcome measures used were the Keele Start Back Tool (SBT), the Roland Morris Disability Questionnaire (RMDQ) and the Numerical Pain Rating Scale (NPRS). The SBT can effectively identify high-risk LBP patients in the primary care setting (Hill et al, 2010). Patients with NSLBP, deemed appropriate for group intervention, and who were identified as ‘medium’ or ‘high’ risk by the SBT, were enrolled in a 6-week physiotherapist-lead ‘Back Care Programme’. Course content included 20 minutes education/group discussion, and 40 minutes of mat-based stretching/strengthening exercises. Personalised goal-setting was strongly supported. The maximum capacity of each class was 8. Those stratified into 1:1 intervention received a combination of individualised manual therapy, exercise prescription and pain education as deemed appropriate by the treating physiotherapist.
Results: 73% of patients (n=58) were stratified into group intervention. Of these, complete pre and post intervention scores were collated for 40% (n=22). T-tests showed these participants achieved a statistically significant improvement in disability (p=0.001) as measured by the RMDQ, and pain (p=0.000) as measured by the NPRS. 63% (n=14) improved by at least one risk category in the Keele SBT classification system. The remainder (n=8) stayed static. None deteriorated. 27% of patients (n=21) were stratified into individual physiotherapy sessions. T-tests showed that these patients also made statistically significant improvements in both disability (p=.001) and pain (p=0.000). 83% (n=10) improved by at least one risk category in the Keele SBT classification system. The remainder (n=2) stayed static. None deteriorated.
Conclusion:The stratified care approach to this cohort of patients resulted in the successful provision of targeted treatment. Both targeted pathways showed clinically significant improvements in both disability and pain scores. The results demonstrate the effectiveness of stratified care pathways in this population. This approach facilitated timely, targeted and clinically effective interventions, while promoting self-management in this challenging population.
References: Hill, J.C., et al. 2010, "Sub grouping low back pain: A comparison of the STarT Back Tool with the Örebro Musculoskeletal Pain Screening Questionnaire", European Journal of Pain, vol. 14, no. 1, pp. 83-89.
Pillastrini P, Gardenghi; et al. 2012. ‘An updated overview of clinical guidelines for chronic low back pain management in primary care’. Joint Bone Spine, 79, pp. 176-185.
Ethical Approval: Service development projects are within the scope of practice of the Physiotherapy Department.
