Information for Doctors

NHS GP LAYCOCK ST GP CONSULT 18 11296

Stratified care for lower back pain

We employ stratified care for our patients with chronic lower back pain.  This involves the use of a brief screening questionnaire to stratify patients into low, medium or high risk of disability.  Treatment is then targeted depending on their risk profile.  This approach has been shown to result in superior clinical outcomes and reduce both societal costs direct health costs (including primary and secondary care consultations)1.  All patients are encouraged to self-manage their back pain, with treatment emphasis being on long-term management, rather than temporary pain relief.

 

Treatment outlines:

Low risk patients are usually treated with a one-off session.  They are taught appropriate back exercises and directed to community exercise schemes.  In addition, current evidence-based management of LBP is discussed, emphasising that pain is rarely due to serious pathology, the importance of keeping active and the prophylactic role of exercise.  Although follow up is not routinely arranged for low-risk patients, their referral is kept open for two months so they can re-book into physio if they experience any problems.

Medium risk patients are treated with conventional physiotherapy depending on the findings of their assessment.  This will usually consist of a structured exercise programme, but may occassionally include other treatments, such as manual therapy or acupuncture.

High risk patients are treated with cognitively informed physiotherapy.  Patients will usually be referred to our physiotherapist-led pain management programme, which uses cognitive behavioural principles to help patients return to desired activities and manage their pain in the long term.

1(Hill JC, Whitehurst GDT, Lewis M, Sterling B, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohara K and Hay EM. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011; 378:1560-1571.)

 

Service outcomes

The following section outlines the changes that our patients undergo following physiotherapy.  It should be noted that not all patients provide post-treatment data (for example due failure to attend follow up).  Data for patients not providing follow-up information is still included in these analyses, with the assumption that these patients have not made any improvement.  It should therefore be noted that the outcomes for patients who complete a full course of physiotherapy are superior to the data presented here.

 

Chronic lower back pain

We have extensively audited the outcomes of our lower back pain service.  Those patients classified as medium risk (low to moderate levels of disability with few psychosocial risk factors) reported significant reductions in both pain and disability after treatment (mean pre-treatment disability RDQ*=9, mean reduction=3.6.  Mean pre treatment pain NRS*=5, mean reduction=2).  Forty-eight percent of patients reported clinically meaningful reductions in disability and fifty-seven percent reported clinically meaningful reductions in pain intensity.

Pre-post treatment changes in patients with medium-risk lower back pain

Measure

Pre-treatment

Post-treatment

Mean change

p

Disability (RDQ*)

9

5.4

–3.6

<0.001

Pain (NRS*)

5

3

–2

<0.001

 

Those patients classified as high risk (moderate-high levels of disability, high psychosocial risk factors) reported larger pre treatment levels of disability and larger reductions in disability post treatment.  Pre-treatment pain intensity was also higher than the medium risk group, however similar reductions in pain intensity were found post treatment.  Sixty-eight percent of patients reported a clinically meaningful reduction in disability and fifty-six percent reported a meaningful reduction in pain intensity.  Postal follow up revealed that these improvements were maintained by the majority of patients one-year after completing treatment.

Pre-post treatment changes in patients with high-risk lower back pain

Measure

Pre-treatment

Post-treatment

Mean change

p

Disability (RDQ*)

16

10

–6

<0.001

Pain (NRS*)

7

5

–2

<0.001

 

*RDQ= Roland Morris Disability Questionnaire (range=0-24)

NRS = Numeric Rating Scale (range=0-10)

 

Chronic neck pain

Patients with chronic neck report significant reductions in both pain and disability, both immediately after completion of treatment and at six-moth postal follow up.  Moreover, fifty-two percent of patients reported a clinically meaningful reduction in neck pain intensity and 48% reported a clinically meaningful reduction in neck pain related disability.

Pre-post treatment changes in patients with chronic neck pain

Measure

Pre-treatment

Post-treatment

Mean change

p

Disability (NPQ*)

49

34

–15

<0.001

Pain (NRS*)

7

4.5

–2.5

<0.001

 

*NPQ= Northwick Park Neck Pain Questionnaire (range=0-100)

NRS = Numeric Rating Scale (range=0-10)

 

Shoulder impingement syndrome

Patients with shoulder impingement syndrome/rotator cuff tendinopathy report significant improvements in pain and disability, even after a short course (three sessions over six weeks) of physiotherapy.  These benefits are maintained at six month follow up.  Six weeks after commencing treatment 46% of patients had made clinically meaningful improvements in shoulder pain-related disability.

Pre-post treatment changes in patients with Shoulder impingement syndrome/rotator cuff tendinopathy

Measure

Pre-treatment

Post-treatment

Mean change

p

Disability (SPADI*)

42

34

–8

<0.001

Pain (VAS*)

60

48

–12

<0.001

 

*SPADI=Shoulder Pain And Disability Index

*VAS=1000mm Visual Analogue Scale

 

Chronic fatigue/chronic widespread pain and fibromyalgia

Patients with chronic fatigue, chronic widespread pain and fibromyalgia are usually treated in a group based rehabilitation programme which is underpinned by cognitive behavioural principles.  Following treatment patients report significant reductions in physical and mental fatigue, disability, depression and anxiety.  These changes are largely maintained at one year follow up.

 Pre-post treatment changes in patients with chronic fatigue syndrome/fibromyalgia

Measure

Mean change

p

Effect size

Disability (SF-36*)

-1.8

0.001

0.46

Pain (VAS*)

-13

0.001

0.56

Fatigue (CFQ*)

-9

0.001

0.74

Anxiety (HADS*)

-1

0.001

0.42

Depression (HADS*)

-2

0.001

0.57

 

*SF-36=Short Form 36

*VAS=1000mm Visual Analogue Scale

*CFQ=Chalder Fatigue Questionnaire

*HADS=Hospital Anxiety and Depression Scale

 

Lower limb osteoarthritis

Patients with lower limb osteoarthritis are usually treated in a condition management programme, which aims to improve exercise participation, minimise symptoms and maximise function.  Following treatment in this four-week group patients report reductions in pain and improvements in physical function.

Pre-post treatment changes in patients with lower limb osteoarthritis

Measure

Pre-treatment

Post-treatment

Mean change

Disability (WOMAC*)

14

12

–2

Pain (WOMAC*)

37

29

–8

 

*WOMAC=Western Ontario McMaster Osteoarthritis Index (disability and pain sub-scales)

 

Pennine physiotherapy research

As well as delivering effective, evidence-based care, we are committed to carrying out meaningful, clinically-orientated research.    Physiotherapy research carried out by Pennine physiotherapy has been widely published in peer-reviewed journals, as well as being presented nationally and internationally. 

Our research portfolio has primarily focussed on the management of long-term conditions.  This has included studies identifying psychosocial factors related to prolonged pain and disability and the testing of novel treatments to improve clinical outcomes.  We have performed interventional studies testing the efficacy interventions for lower back pain, neck pain, shoulder impingement syndrome, chronic fatigue syndrome and fibromyalgia.  Our work includes two randomised control trials as well as several longitudinal and cross-sectional studies.  For a full list of publications and conference contributions, please click here.