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GPs should make the most of the tools available for lower back pain

Letter from Dr Adrian Chudyk, GP research fellow at Keele University and GP in Leek, Staffordshire

Compared to the previous NICE lower back pain (LBP) guidelines (May 2009) one of the most prominent changes in the new advice, expected to be published in September, is against the use of any analgesia, as addressed by Copperfield when it was released for consultation, and early inclusion of stratified care for LBP. The former, albeit slightly disconcerting, does not require any explanation, the latter involved NICE’s recommendation to use the STarT Back Tool (STB) and to provide matched treatment pathways. If you have not yet used it in clinical practice, it may be prudent to familiarise yourselves with it. STB approach was developed as far back as in 2008 and validated as a risk stratification tool. It proved beneficial for patient care (improvements in disability, fear avoidance beliefs, satisfaction, and reduced time off work) and was cost effective (reduced use of healthcare resources by avoiding inappropriate referral to physiotherapy and significantly reduced societal cost associated with absenteeism).

The STB tool is surprisingly easy to use. It consists of nine questions, most commonly asked by the GP during the history taking part of consultation. The tool is quick to complete and easy to score. The low risk subgroup of patients can be safely managed in GP consultation with education, advice and reassurance and then discharged. Medium risk patients receive an evidence based course of physiotherapy and high risk patients receive psychologically informed physiotherapy (PIP), provided by physiotherapist who received additional training. It is important to emphasise that STB Tool does not substitute but complements the clinical judgement of a GP.

The use of the STB Tool adds less than one to two minutes to a consultation and in return it instantly rewards clinician with reduced diagnostic uncertainty for back pain outcome, as well as shorter physiotherapy waiting time for appropriate patients.

The current NICE guidance (basing its decision on available evidence) leaves GPs with very little in terms of LBP interventions at our disposal. It is therefore even more important to ensure we understand and utilise available evidence based approaches to manage our low back pain patients effectively. From the clinicians’ point of view, arguably the most significant benefit of STarT Back approach is assisting us in reassuring low risk patients, thus reducing unnecessary re-presentations. We know it works, why not use it?

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Readers' comments (4)

  • Erm.. because I think patients would think we are beyond useless / incompetent if we were NOT to offer significant analgesia.

    These guidelines are probably the LEADING example of where patients / ivory tower 'research' doctors ideas are planets apart ! Wise up !

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  • The researchers and/or contributors to the nice guidelines have obviously never experienced truely awful back pain.
    Research might show analgesia makes little difference but trying telling that someone who can't move due to pain let alone do back exercises!

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  • And where on the tool are the RED FLAGS???

    Previous history malignancy
    Age 1650 with NEW onset pain
    Weight loss (unexplained)
    Previous longstanding steroid use
    Recent serious illness
    Recent significant infection

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  • In my experience most people with mechanical back pain don't come for explanation of their symptoms or reassurance. They come for analgesia so that they can continue with their lives.
    Not sure this piece of guidance is applicable to my average patient.

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