Dr Hugh SturgessExecutive DirectorPennine MSK Partnership Ltd

Implementation of STarT Back in Oldham

Low Back Pain

• Low back pain between the 12th ribs and the buttock creases

• 1/3 population affected at some time each year

• 20% will consult their GP• Commonly simple non-specific LBP• One year prevalence of chronic low back pain

is c1%

Impact of Back Pain

• 3.5 million people per annum develop back pain in the UK

• 6-9% of adults consult their GP each year with back pain

• 60-80% still report some pain or disability at 1 year

• 40% of those who have taken time off work will do so again

• Societal costs equivalent to 1-2% of GDP

Low Back Pain• Simple/mechanical

• Most common, usually settles without intervention, promote positive attitude, self care, keep active, early return to work and avoid medicalisation

• Back pain with nerve root pain• Sciatic or femoral nerve root, cauda equina syndrome and spinal

stenosis

• Inflammatory• Worse at night, buttock pain, eased by activity

• Possible Serious pathology – red flags• <20 or >50, PH cancer, steroid use,

immunosuprression/compromise, IV drug use, fever, weight loss, pain worse at night, thoracic

STarT Back

• Stratified• Targeted• Treatment for patients with• Back pain

• Developed by Keele University in 2007• http://www.keele.ac.uk/sbst/

• Appropriate for patient with simple low back pain or back pain with radiculopathy

STarT Back

• Ideally assessed at first presentation of back pain• Can however be undertaken at any time• Stratifies a patient to a management approach

dependent on the physical impact and/or psychological impact of their pain

• Low risk patients can access physiotherapy if they request it or fail to improve after 2-4w

• Patients can also still go on to the NICE CG88 interventions after initial management if they have failed to improve

Targeted Treatment

1. Low-risk Manage in Primary Care

2. Medium-risk Referral to Physiotherapy

3. High-risk Referral to Physiotherapy

Individual treatment:

- History- Physical examination- Self management- RCGP Back Book (TSO)- Advice sheet- www.youtube.com/watch?v=ZumxS6DX-5o - Local exercise venues- Positive attitude, encourage an early return to work and keeping physically active- Referral to CareUK physiotherapy if patient requests or not improving after 2-4 weeks

Low-risk minimal care plus:

- 45 min assessment - Up to 6 x 30-min sessions- Advice (written) - Individual management plan- Aim to reduce pain & disability - Promote physical activity- Exercise, general & specific- Manual therapy- Return to work advice- Pain medication compliance- Mentoring

Low-risk minimal care plus:

Medium-risk physical treatments plus:

- 60 min assessment - Up to 6 x 45-min sessionsIn addition:- CBT approach- Goal setting- Addressing beliefs- Progress monitoring- Return to work planning - Mentoring

STarT Back Screening Tool

(SBST)

Explanation to the Patient• Low Risk• Physiotherapy treatment will focus on giving you the skills to reduce the risk of re-

occurrence and address any underlying stiffness and restriction which may be holding you back from your normal daily activities. It will concentrate on self-management techniques

• Medium Risk• Physiotherapy treatment will focus on addressing stiffness and any other restriction which

may be stopping you from your normal activity. This may include some hands-on treatment but will certainly include exercise, advice and education to reduce the impact of your issue enabling you to return to most of your normal activities as soon as possible.

• High Risk• Physiotherapy treatment will focus on addressing issues of stiffness and loss of function as

a result of your back pain. It will also aim to address issues which develop as a result of being in pain and having a restriction in normal activities for a period of time such as mood, sleep, anxieties and worry about the issue for the long-term. Treatment will include a lot of advice, explanation, exercise and may include some hands-on treatment with the focus on reducing the impact of the issue on your normal day to day activities.

Outcomes

IMPacT Study - Outcomes at 6 MonthsRef: Foster NE, Mullis R, Hill J, et al. Effect of stratified care for low back pain in family practice (IMPaCT Back):a prospective

populationbased sequential comparison. Ann Fam Med. 2014;12(2):102-111http://www.annfammed.org/content/12/2/102.full

• Small but significant benefit relative to usual care as seen from a mean difference in Roland-Morris Disability Questionnaire scores of 0.7 (95% CI, 0.1-1.4)

• With a large, clinically important difference in the high risk group of 2.3 (95% CI, 0.8-3.9)

• Mean time off work 50% shorter (4 vs 8 days, P = .03) • Proportion of patients given sickness certifications

30% lower (9% vs 15%, P = .03)• Health care cost savings were also observed.

Implementation in Oldham

• Commencement planned for 1st October 2014• Cluster/Practice based training (Positive feedback from training

already delivered)• Mandatory use of the SBST for patients with back pain and

back pain with radiculopathy. PCFT will reject if no SBST.• Resource pack

– Implementation letter– STarT Back scoring algorithm– Back pain self care leaflet– Back book– Link to youtube video– Back pain management/referral guides– Sample referral rejection letter

• Peer review of referral rejections, significant events etc at cluster meetings

• Targeted follow up training as required

Why the Mandatory Use of the SBST?

• Evidence from implementation elsewhere eg Sheffield

• Ensures Primary Care manages low risk patients

• Encourages an understanding of back pain in a more bio-psycho-social model

• Evidence this reduces inappropriate advice, prescribing and interventions

Any questions?