Uptake and use of the stratified care approach (STarT Back) for low back pain


To share how and where the stratified care approach (SB) for low back pain is being used globally and to capture barriers and facilitators to its uptake.


An online questionnaire was co-designed by a web developer, a consultant physiotherapist and a project manager. Key themes explored geographical location, profession, the use of the STarT Back approach, and barriers and facilitators to its uptake. Questions were a combination of closed and free text responses. It was tested by 10 primary care based physiotherapists and alterations made prior to distribution. Completion was voluntary and was highlighted via social media, clinical networks and e mail contacts.


Up to April 2017, 94 respondents completed the questionnaire. The majority of the responders were from Europe (75%), the least from Africa (2%). Over half were state funded Physiotherapists (53%),16% private Physiotherapist and 6% General Practitioners. The majority were based in primary care (56%) and 23% in secondary care (23%).

When asked 'how did you hear about SB', a research publication was the most popular response (40%), with conference presentation (23%) and personal contact (23%), website (14%) and a training event (12%).

77% were using SB, 18% were not and 5% 'did not know' if it was being used, 49% were using it as an outcome tool. The majority were using SB on an individual basis (75%), with 16% using on individual and group settings, 1% used solely in group setting.

29% had undertaken an audit of its use. 36% of responders had received SB training at Keele University. Almost half (46%) reported SB being used in local clinical pathways (27% identified it wasn't and 26% did not know).Whilst 37% suggested they were collaborating with other clinicians around stratified care, only 6% have involved patient engagement activity.

There were 84 free text responses about barriers to implementation. Common themes were lack of time and GP engagement, lack of training, poor compliance and language. When asked what could improve uptake (71 responses), common themes were: engagement with GPs, use of clinical champions, use of Front Line Practitioner roles, improved training and patient and public involvement.


The majority of the respondents were from Europe and so give us a good overview of how and where SB approach is being used. There are examples of where it is being utilised in clinical pathways globally and evaluations are being undertaken, however further work needs to be undertaken to explore uptake outside of a European setting.

Implementation work still needs to focus on engaging the broader healthcare team including physiotherapists, GPs and nurses. Greater emphasis needs to be placed on public and patient involvement in highlighting the clinical and cost benefits of this approach and greater access to training is needed.

Funding acknowledgements

KD is part-funded by a Knowledge Mobilisation Research Fellowship (KMRF-2014-03-002) from the NIHR, the NIHR Collaborations for Leadership in Applied Health Research and Care West Midlands and the West Midlands Academic Health Science Network. The views expressed in this paper are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

Additional notes

This work was presented at Physiotherapy UK 2018