STarTBack
Gordon Smith
Physiotherapy Team Leader at Evesham Community Hospital
and Pershore Hospital &
Senior Lecturer at University of Worcester
Kay Stevens
Consultant Physiotherapist, Keele University
24 May 2016
Objectives
By the end of this session you will:
• have a clear understanding of the STarTBack screening tool and
how it can be used to guide patient management
• understand how to identify low, medium and high risk subgroups
• have a basic understanding of how each group should be best
managed
• have more strategies for managing pain behaviour
• have reflected on your own approach to the management of
patients and identified at least one change you will make
• have received an update on the process of implementing
STarTBack at ECH
• have had the opportunity to participate in a discussion regarding
how best to implement STarTBack
• agree next steps
Overview of the SB tool
• STarT Back stands for S ubgrouping and Tar geted T reatment
for low B ack pain
• Stratification = group + treat
• Biopsychosocial tool
• 4 physical and 5 psychosocial elements
• We can affect all factors in SB i.e. it does not include age or
sex etc.
• Our clinical intuition is not as good as we think!
Overview of the SB tool
• SB made a big difference to how pts were managed by
physios.
• 50% low risk referred for physio in control but only 7% in the
trial.
• Med risk was 60% v 98% and
• High was 65% v 100%.
Identification of the 3 subgroups
4 biological questions and 5
psychosocial
Comorbid pain
Overall impact
Disability
Fear avoidance
Catastrophising
Depression
Disability
Referred pain
Anxiety
Management of the 3 subgroups
Low risk
•
•
•
•
•
•
•
•
Reassurance
Prognosis
Not serious
No investigations
Keep active
RTW ASAP/stay at work
Good analgesia
Advice re recurrence
Management of the 3 subgroups
Low risk
• Low risk patients do WORSE when not
discharged after one session
• Managed in a 30 mins slot with physios,
including objective assessment and then
given all the advice etc. (GPs managed it in
less time).
• Do not place on standby
• We know low risk will do well with 30 mins +
video
Management of the 3 subgroups
Low risk
• The truth about LBP
Management of the 3 subgroups
Medium risk
• Basically normal physio treatment
• Could include acupuncture and manual
therapy
• Average of 4 physio sessions
• Bed rest, traction, massage and
electrotherapy NOT recommended
Management of the 3 subgroups
High risk
• “Education is to behaviour change as
spaghetti is to a brick” (Fordyce, 1988).
• i.e. simple education is not enough.
• Education is necessary it is seldom sufficient.
• Information giving is a weak way to produce
change.
• Popularity should not be confused with
effectiveness.
Managing pain behaviour / basic CBT
approach
Graded activity/exercises
• Avg of good day and bad day and go below
• Patient chooses starting point
• Slow progressions
• Write an agreed plan for the week
• Patient sticks to it on good and bad days
• Notes kept
• Positive reinforcement
Managing pain behaviour / basic CBT
approach
Graded activity/exercises
• Adopt a flexible approach
• Rate difficulty and progress when < 5 or 6/10
• “How much of that activity could you do now
and still be active and do the same things you
want to do tomorrow and the rest of the
week?”
Managing pain behaviour / basic CBT
approach
• Setting an agenda is part of CBT.
• Determine at start what pt wants and how long
you have.
• What is important to them as well as what is
important for them.
• Good come backs: "I'd like to help/Thank you
for telling me that/sharing that with me/You
seem...”
• Empathy
Managing pain behaviour / basic CBT
approach
• Goal setting – values based
Goal setting – values based
Goal setting – values based
Managing pain behaviour / basic CBT
approach
Integrating bio and psychosocial:
• You do not need to reduce pain to increase function
• Shift from pain control to living with the pain agenda
• "I can't say for sure that your pain won't reduce or go
but..."
• "Let's focus on what we can change."
• In people in acute pain we are still increasing
meaningful living.
• Everyone with chronic pain onset had acute pain.
Iatrogenically induced pain
Iatrogenically induced pain
• What are the potential -ve consequences of
investigations? Does a normal investigation reassure?
• ↑ stress/anxiety because you are sending them for a
scan
• ↓ effectiveness of physio whilst awaiting scan
• ↑ rate of surgery and further investigations if had a
scan
• radiation risk
• people who get a scan are no more satisfied but more
anxious
Iatrogenically induced pain
• Check pts understanding if you have shown
them a scan - ask them to explain it back to
you.
• Why are we giving pts a copy of their scan if
the evidence is that this is potentially
harmful and certainly not helpful?
Impact of SB
Lancet article 2011 "Stratified management..." => improved
outcomes, improved pt satisfaction, much less time off work,
=> cheaper by £34 and societal costs by £675.
Cost savings:
1. ↓ GP consultations
2. ↓ visits to consultants
3. ↓ investigations
4. ↓ epidurals
5. other providers of health care
6. ↓ drugs
7. ↓ time off work (= health promotion for commissioners).
Impact of SB
“...using the STarTBack tool as a decision making tool in primary
care can reduce overall (physiotherapy) referral rates...”
Dr. Ollie Hart
Summary
• STarTBack has good evidence in support of it
• It can successfully identify low, medium and
high risk patients
• The 3 groups should be managed differently
• We need to implement it
Average number of face to face appointments attended and average
number of weeks attended for physiotherapy (excluding all patients that
were managed solely by Physio Direct)
Low
Medium
High
Average No. of
face to face
appointments
3.11
3.73
3.27
Average No. of
weeks attended
for physio
3.79
4.15
3.72
Results
• For the 28 low risk patients, 59 appointments were
given.
• If SB was successfully implemented it would be
envisaged that ideally all low risk patients would only
attend for one appointment.
• This would suggest a potential saving of 31
appointments for these 28 patients.
• This would suggest a potential saving of 111
appointments per 100 low risk patients equating to ~
£2,000 per 100 low risk patients if all low risk patients
were managed in a one off appointment.
Results of implementation –
Data for Low risk
Total No. seen
only once
19
No. discharged at Total No. seen >
Evidence that pt
initial
once
was given video
appointment
link
12
3
16
(one seen 3 times
one seen 4 times
and one seen 7
times)
Average no.
appointments
1.5
(↓ by 1.61
appointments;
over 50% ↓in no.
appointments)
Agreement of next steps
Thank you
Gordon Smith
01386 502464
[email protected]
References
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•
•
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Fritz JM, Beneciuk JM, George SZ. Relationship between categorization with the STarT Back Screening
Tool and prognosis for people receiving physical therapy for low back pain. Phys Ther. 2011;91:722–732
Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, et al. A primary care back pain screening tool:
identifying patient subgroups for initial treatment. Arthritis Rheum 2008;59(5):632–41
Hill et al. Comparing the STarT Back Screening Tool's Subgroup Allocation of Individual Patients With
That of Independent Clinical Experts.Clinical Journal of Pain: 2010 - Volume 26 - Issue 9 - pp 783-787
Hill J, DGT Whitehurst, Lewis M, et al. A randomised controlled trial and economic evaluation of
stratified primary care management for low back pain compared with current best practice: The STarT
Back trial [ISRCTN37113406]. Lancet 2011 (In press).
Sowden G, Hill JC, Konstantinou K, Khanna M, Main C, Salmon P, Somerville S, Wathall S, Foster N.
Subgrouping for targeted treatment in primary care for low back pain: the treatment system and clinical
training programmes used in the IMPaCT Back study (ISRCTN 55174281) Family Practice 2011 (Online
ahead of print)
http://fampra.oxfordjournals.org/content/early/2011/06/27/fampra.cmr037.full.pdf+html
Whitehurst DG, Bryan S, Lewis M, Hill J, Hay EM. Exploring the cost-utility of stratified primary care
management for low back pain compared with current best practice within risk-defined subgroups. Ann
Rheum Dis 2012; 71(11): 1796-802.