SPLIT program: Stratified care for enhanced outcomes in low back pain management

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Background and goal: Low back pain, or LBP, challenges health systems worldwide. To mitigate persistent disabling LBP, the implementation of a stratified approach in primary care has been suggested. This strategy involves aligning specific treatments with distinct patient subgroups. The StarT Back trial demonstrates the effectiveness and cost effectiveness of the stratified approach for LBP using the StarT Back Screening Tool (SBST), which categorizes patients into low, medium, and high risk of developing persistent disabling pain. This approach suggests matched physical therapy treatments of increasing dosages and complexity according to risk subgroups. The goal of this study was to determine the effects of a stratified approach (SPLIT program) in reducing back-related disability of patients with LBP in primary care.

Study approach: Conducted with the Regional Health Administration of Lisbon and Tagus Valley, the study involved 7 health units of the Arrábida health center group. It enlisted 447 participants, using a before-and-after design with two sequential, independent patient groups. From February to September 2018, family physicians managed the initial group of 115 patients according to usual care, unaware of the SPLIT program. The second phase involved training and mentoring primary care–based physical therapists (PT) in a structured program to potentiate the implementation of a stratified care approach, the SPLIT program. This phase included training PTs in assessing patients' disability risk, matching treatments to risk levels, and tracking outcomes. Family physicians were presented with the SPLIT program, including the latest recommendations for managing LBP to enhance recruitment and referrals to PTs. In phase three, from November 2018 to October 2021, usual care continued but added referrals of eligible patients to primary care–based physical therapists for the SPLIT group, comprising 332 participants. Health outcomes for both groups were assessed via telephone at two and six months, focusing on back-related disability, pain intensity, quality of life, and perceived effect of treatment.

Main results: The average age of the participants was about 46 years old. Most of them were women and the majority were employed. The SPLIT group was slightly younger. LBP symptoms were generally less severe in the SPLIT group.

  • Over six months, significant improvements in back-related disability, pain, and health-related quality of life were observed in the SPLIT group compared to the usual care group.
  • The first group of patients were mainly treated by family physicians with pharmacological treatment (85.3%). Nonsteroidal anti-inflammatory drugs (81.4%) and muscle relaxants (60.8%) were the most frequent, followed by weak opioids (19.6%). Only 8.3% of patients were referred for physical therapy.
  • In the SPLIT group, an average of 3.76 physical therapy sessions were provided: 1.11 for patients with low risk, 4.48 for medium risk, and 9.98 for high risk.

Why it matters: The SPLIT program can significantly improve outcomes in patients with low back pain. The SPLIT program's success indicates that tailored care strategies can benefit a broad spectrum of patients, not just those at the highest risk. Further research should assess the cost effectiveness of the SPLIT program.

Journal reference:

Gomes, L. A., et al. (2024) A Stratified Approach for Managing Patients With Low Back Pain in Primary Care (SPLIT Program): A Before-and-After StudyThe Annals of Family Medicine. doi.org/10.1370/afm.3104.


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