Early Back Groups - Is this an effective way to manage all patients referred with Low Back Pain?

Purpose

In Swindon spinal patients make up 50% of all musculoskeletal physiotherapy referrals. In common with physiotherapy departments nationally, there is an ever increasing demand on resources, pressure to manage waiting lists and deliver timely effective treatment.

We have been looking into addressing these problems and innovative ways to develop our services. One of these was setting up an Early Back Group (EBG).

We have struggled to achieve compliance by GPs at the point of referral to complete the STarT Back Screening tool.

The purpose of this study was to evaluate whether a non-stratified approach is effective at delivering early minimal physiotherapy intervention to all patients with Low Back Pain (LBP), regardless of risk factor.

The STarT Back score was
27% low, 36% medium and 37% high for the Swindon population.


Of the patients that were discharged,
only 14% were re-referred within a year (21% low, 28% medium and 51% high).
A total of 70% of all patients
were discharged at 6 weeks.


82% of low group,
69% of medium group and 62% high group were discharged at 6 weeks.

Approach

Patients referred into physiotherapy with LBP who meet the inclusion criteria (no complex co-morbidities or communication difficulties) are referred into an EBG. The patient books into an EBG and is seen within two to three weeks of being referred.


Patients are given a STarT Back questionnaire to complete prior to attending the EBG. The EBG is a class of 2 hours of advice and exercises, which are recommended by the Arthritis Research Council. Patients are screened for Cauda Equina syndrome and those with more severe problems can be triaged and treatment given sooner. Following the class, patients can opt in for 1:1 physiotherapy after 4 weeks or are discharged at 6 weeks. The classes are run by three Spinal Advanced Physiotherapy Practitioners.


A sample of 397 patients that attended EBGs was reviewed. The STarT Back data was analysed to ascertain the numbers in each risk group and those that opted for treatment.

For those not opting for treatment, the percentage that were re-referred within a year were reviewed to ascertain if there were any trends with regards to their risk level on the STarT Back tool. For patients that arranged further treatment, the number of sessions of physiotherapy was counted. If they had an MRI or other intervention (injection/surgery) this was noted.

Outcomes

The STarT Back score was 27% low, 36% medium and 37% high for the Swindon population.


82% of low group, 69% of medium group and 62% high group were discharged at 6 weeks. A total of 70% of all patients were discharged at 6 weeks.


Of the patients that were discharged, only 14% were re-referred within a year (21% low, 28% medium and 51% high).

There was no notable difference in the number of treatment sessions given between groups that opted in.

The EBG is an effective pathway for managing all patients with LBP regardless of risk stratification. A greater proportion of patients opt-in for treatment as the risk factor increases.
Success may be due to early intervention and the expertise of those delivering the class.

Further research is needed to establish more long-term efficacy of this strategy.

Further research is needed regarding the group of patients that did not opt into an EBG

Implications

The EBG model of expert early intervention could be adopted nationally as an effective way of managing LBP.

Funding acknowledgements

No funding given.

Additional notes

This work was presented at Physiotherapy UK 2019