Integrating physical and psychological approaches to treatment in low back pain: the development and content of the STarT Back trial's ‘high-risk’ intervention (StarT Back; ISRCTN 37113406)

Abstract

A new randomised controlled trial of intervention in low back pain has been described recently. In this trial, a screening and targeted approach was found to be more effective and cost-effective than current best practice. Nested within the intervention arm were three different interventions targeting patients identified as ‘low’, ‘medium’ or ‘high’ risk dependent on the presence of (mainly) psychosocial risk factors. In this paper, the development and content of the STarT Back trial's ‘high-risk’ intervention is described. It offers a systematic approach, termed ‘psychologically informed practice’, to the integration of physical and psychological approaches to treatment for the management of people with low back pain by physiotherapists. The term ‘disability’ is used to refer to self-reported pain-associated functional limitations, and ‘psychological’ is used to refer to the beliefs/expectations, emotional responses and behavioural responses associated with low back pain.

Introduction

The recent National Institute for Health and Clinical Excellence guidelines for low back pain recommend a combined physical and psychological treatment programme for patients with low back pain presenting with a high level of disability or distress [1], although there are no specific guidelines on how to do this. Previous research in this field has demonstrated that although cognitive-behavioural approaches appear to be acceptable to patients, and are able to achieve comparable clinical outcomes to other active interventions [2], evidence for their superiority over other treatments is far from robust. A recent Cochrane review of clinical trial evidence concluded that the benefits from the use of early psychosocial interventions for patients with musculoskeletal pain were limited [3]. In low back pain, a number of plausible reasons have been suggested to explain these findings, including: the selection of heterogeneous patient populations in clinical trials; insufficient targeting of interventions on modifiable risk factors; insufficient competencies of care providers; insufficient intensity or duration of the intervention; inadequate adherence to treatment protocols; and inadequate assessment of outcome [4]. Alternatively, it may be that psychosocial interventions are ineffective. However, a recent trial in chronic low back pain demonstrated the superiority of a group cognitive-behavioural therapy intervention package compared with usual care in terms of more effectiveness (Roland and Morris Disability Questionnaire) at 1 year, and cost-effectiveness, mainly as a consequence of the group treatment format [5]. Further research is clearly needed.

In response to the limitations described by van der Windt et al. [4], the present authors developed a novel way of stratifying patients with low back pain according to prognostic risk factors, and targeting treatment accordingly [6]. This new approach to stratifying for targeted treatment (the Keele STarT Back approach) is currently being evaluated in clinical studies [7], [8]. The aim of this paper is to describe the rationale, development process, key learning objectives, structure and methods of delivery of the training package for physiotherapists delivering treatment to those patients classified as ‘high risk’ for poor outcome in the future.