Keele University in Staffordshire, England is fifty years old and educates 10,000 undergraduates on a square mile of land once owned by the same family for four centuries and prior to that by the medieval Knights Templar. Their arthritis research unit has published an interesting paper comparing usual care of low back pain with a new approach based on stratifying patients into three groups (1).
They begin by pointing out that 6-9% of adults in the UK see their GP about back pain annually and only about 1/3 are free of pain or disability a year later. It is clear these patients are not homogeneous, but not clear what treatment is best for each individual. Consequently the authors administered a previously validated 9-item questionnaire to stratify back pain patients into those with low, medium or high risk for persistent disability. Interestingly, high risk for disability is predicted by positive answers to at least four of the five items on the psychosocial sub-scale of the questionnaire and 28% fell into this group.
The patients were randomly chosen either to be in a control group who received usual care, or in a study group where treatment was tailored to their disability risk. All in the study group received an assessment and educational information, those at medium risk also received referral to a physical therapist (PT) and those at high risk received referral for “psychologically informed” physical therapy.
The primary outcome of this research was the score on a questionnaire measuring disability. In the low risk group, even though about 1/2 the control subjects were referred for physical therapy compared to almost none in the study group, there was no difference in outcome. For those at medium risk, about 1/3 in the control group were not referred for physical therapy compared to nearly all in the study group and the latter had a better outcome at 4 and 12 months later. In the group at high risk for disability, again about 1/3 in the control group were not referred for PT compared to nearly all in the study group, but here although there was a better outcome in the study group at 4 months, this improvement was lost at 12 months. Taken as a whole, the study group also had better outcomes for fear, depression and tendency to catastrophize their situation. In addition, health care costs and days off work were lower for the study group while treatment satisfaction was higher.
This research documents a significant benefit in outcomes, costs and satisfaction with treatment in patients with back pain when psychological factors are assessed and used to guide treatment. I strongly suspect that if psychological factors had been assessed in more detail and treated by mental health professionals rather than physical therapists that the long term outcome in the high risk group would have been substantially better. Nevertheless, this paper is an important step in bringing care of back pain into the 21st century.
1. Hill JC et all. Comparison of stratified primary care management for low back pain with current best practice (StarT Back): a randomized controlled trial. Lancet Oct 2011; p 1560 – 1571.