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Implementation of the back skills training intervention

Back pain is the most common disabling condition in the world. Most people will experience low back pain at some point in their life, and for some, this will be a chronic and enduring health problem.

The impact of back pain is spread across a wide range of functions including mobility, bending, lifting, carrying, and sitting. It can stop people from working, and hence carries an economic burden, as well as impacting on ability to sleep and enjoy a good quality of life. In older people, it reduces mobility and function.

Back pain results in high levels of consultation in primary care with associated onward referral to physiotherapy, imaging, surgery and invasive procedures. The NHS pays substantial sums of money for the management of low back pain (LBP), often with modest or disappointing returns.

In early and middle life, back pain is not usually associated with an easily identifiable pathological cause. Although our understanding of the pathogenesis remains poor, important mediators and possible causes have been identified. Notably, physical inactivity and the way in which people think about pain and inactivity, for example holding negative beliefs.

Recognising the evidence that traditional therapies, including structured exercise classes, GP care and manipulation/therapy, provided at best, only a modest short term impact on LBP, in 2006 the HTA commissioned a trial of cognitive behavioural therapy for low back pain from our research group.

Led by Professor Sallie Lamb the group, comprising of physiotherapists and cognitive behavioural therapists, designed a new intervention (termed the Back Skills Training Intervention, BeST) that targeted unhelpful thinking about pain and activity, and included a behavioural intervention to promote physical activity and exercise. This was not about doing exercises in a class, rather about helping people to think differently about their pain, engage positively with physical activity as method of controlling pain and helping return to normal life. We intended to give people skills and advice about what to do with set-backs, flare-ups and not feeling like doing anything. Importantly, it was delivered in a group setting, to quite large unselected groups of people with LBP.

We conducted a randomised controlled trial which demonstrated that the intervention was effective over a prolonged period (we studied people for about 3 years), and that the BeST intervention was the most cost effective intervention available for LBP to date (most likely due to the group format). 

We are now working on tackling the challenges of implementing the Back Skills Training Trial into clinical practice and looking into improved pathways for behavioural management of lower back pain, in the following ways:

  • A systematic review of the effectiveness of CBT for LBP and a review of the implementation issues associated with CBT. 
  • Working with local commissioners, practitioners and managers, to gain a broadened understanding of the complexities of commissioning LBP services, and investigate necessary changes in clinical pathways.
  • Undertaking additional statistical analysis of the original BeST data set confirming that it is not necessary to triage patients, and also that confirm the key mechanisms of the intervention.

If you are interested in this work and would like to know more about implementing the Back Skills Training Trial into clinical practice, please contact Dr Beth Fordham