Title: Optimal management of spinal pain and sciatica in primary care
Funder: Department of Health (England)

Abstract: AIMS AND OBJECTIVES To improve the primary care management of back pain and the health of patients with back pain through “subgroup-and-target treatment” approaches. Linked studies will use physical (leg pain), psychological (illness perceptions and self efficacy) and social (work-loss and sickness certification) characteristics, demonstrated in previous research to be important risk factors for poor long-term outcome, to identify subgroups of patients who can be targeted for appropriate management. In three phases, we will: 1) Define and understand the problem of back pain in primary care in the context of the biopsychosocial model that underpins clinical guidelines, 2) Develop and test targeted interventions aimed at reducing the major long-term consequences of back pain such as disability and work-loss, 3) Evaluate integration of the new models into primary care and investigate their cost-effectiveness. BACKGROUND Back pain is a common, disabling condition with high personal and economic costs. Despite available guidelines for practice, there have not been tangible reductions in the population prevalence of back pain or its serious long-term consequences. We hypothesise that one reason for this is that the “one-size fits all” approach fails to target treatments at patients who might benefit from them most, thus diluting any benefits. RESEARCH PLAN Our programme consists of three workstreams, each addressing one domain of the biopsychosocial model through a specific example (leg pain; illness perceptions and self-efficacy; work-loss and sickness certification). Each workstream will progress through the three phases. PHASE 1 uses statistical modelling, reviews of published data and further analyses of trials, observational and qualitative data, to refine and validate ways to identify the relevant subgroups of patients in each workstream. PHASE 2 uses mixed qualitative (consensus studies, interviews, training and evaluation) and quantitative methods to: a) Develop a standardised clinical assessment, agree optimal management pathways, and pilot procedures for a clinical implementation study, focused on leg pain in back pain sufferers b) Develop and test a targeted intervention for the subgroup of patients with psychological obstacles to recovery, including training programmes for healthcare practitioners c) Develop a new model of care to help back pain patients stay at work and to train primary care clinicians to deliver this PHASE 3 will evaluate the practicality and clinical and cost-effectiveness of the proposed new ”subgroup-and-target treatment” approaches. We will: a) Evaluate potential health and economic gains from implementing a systematic approach to identifying and treating leg pain in primary care (clinical implementation study) b) Investigate the clinical and cost-effectiveness of targeted treatment for the subgroup of patients whose perceptions and beliefs about their back pain are obstacles to recovery (randomised controlled trial) c) Evaluate the feasibility and effectiveness of a practice based intervention aimed at reducing sickness certification in general practice (non-randomised comparison study). The RESEARCH TEAM is based on a long-standing collaboration between NHS organisations in North Staffordshire, Cheshire, and Keele University which has delivered observational and interventional research programmes, drawing on well-developed user involvement, Keele’s strength in applied musculoskeletal research using a wide range of methods (epidemiological, clinical trials, qualitative), and an established collaboration with Birmingham University Health Economics Facility. The partnership between the academic Centre & Consortium of NHS partners has built a strong multi-disciplinary infrastructure, in both the clinical and academic settings, with clear commitment from service managers and clinical directors to support research and its translation into clinical practice. This research environment supports clinical practitioners to engage in research, ensures successful recruitment and follow-up of study participants, and supports an ethos of training across academia and clinical partners involved in large mixed method studies. MAIN OUTPUTS will be clear methods for operationalising approaches that subgroup and target treatment for back pain patients in primary care; enhanced skill sets of practitioners; training and educational materials; clear information about the practicality, acceptability, benefits and costs of these targeted approaches. Some components may apply more widely than back pain, such as best consultation practice in approaching sickness certification. PUBLIC ENGAGEMENT Patients from our well established Users’ Forum, and individual back pain sufferers known to us through involvement in previous studies, have helped to develop the proposed programme. Patients will continue to be involved through the steering and consensus groups, and the Users' Forum.


Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: MUSCULOSKELETAL;NEUROLOGICAL