Title
Classification-Based Group Functional Therapy (CLASTER) in Subgroups of Patients with Non-Specific Chronic Low Back Pain (NSCLBP).

Lead researchers
Dr Liba Sheeran, Dr Valerie Sparkes, School of Healthcare Studies, Cardiff University


Introduction
This pilot study, originally planned and costed for a duration of 2 years, has received £20,000 from WSPCR to support Year 1 (Jan 2012 – Dec 2012) objectives, with a view to apply for final year funding upon completion of the Year 1 objectives. All Year 1 objectives have now been met and the study runs on schedule and on budget. This final year report details the progress to support a grant application for Year 2 funding for which a submission has been filled together with this report.

Original Study Question
To investigate whether delivery of classification based therapies for NSCLBP is 1) feasible in a clinical primary care setting, and 2) has the potential to benefit NSCLBP patients in terms of pain, function, physical activity, spinal posture and movement behaviour.

Study 1: 
Method/Design
Implementation and delivery of classification-based targeted treatments to manage NSCLBP in primary care: Views of managers and clinicians Methods: Data from 3 semi-structured interviews with physiotherapy service managers and advanced spinal physiotherapy practitioners and a focus group (5 physiotherapists) in two NHS Health Boards, South Wales, UK, was thematically analysed.

Results
Five themes emerged. CS knowledge: Clinicians and managers know different classification systems (CSs) and agree with its usefulness. Clinicians have specific CSs knowledge, managers viewed classification related to referral pathways and prognosis. Current CS use: Clinicians classify using their experience and clinical reasoning skills shifting between multiple CSs. Managers are confident that staff provide evidence-based service though believe classification is not always practiced across services. CS advantages and disadvantages: Effectively targeting the right patients for right treatments using evidence-based practice is advantageous. Prevalence of “guru led” CSs developed for research and of limited clinical use is disadvantageous. Barriers: Patients’ treatment expectations, threat to clinical autonomy, lack of sufficiently complex CSs, lack of resources to up-skill clinicians and overall CSs fit into complex referral pathways. Enablers: CSs sufficiently complex and placed within clinical reasoning process, mentoring for inexperienced staff, positive engagement with all stakeholders and patients. Conclusion: Clinicians and managers are aware of CSs and agree with its usefulness to guide LBP management. Clinicians classify LBP, though there is no formalized CS process in place.  Whilst clinicians view classification as the relationship between patients and physiotherapy managers have a broader whole service view.

Study 2:
Method/Design
Exploratory study investigating the effect of CLASTER in subgroups of NSCLBP. Methods: Pragmatic controlled feasibility study comparing the effect of CLASTER with current best care in NSCLBP. The primary outcome was the effect of CLASTER on the Oswestry Disability Questionnaire (ODQ)1. Secondary outcomes included pain (visual analogue scale, VAS), physical activity (International Physical Activity Questionnaire, IPAQ), fear-avoidance of movement and (re)injury (Tampa Scale for Kinesiophobia, TSK)2 and The Distress and Risk Assessment Method (DRAM)3. A nested biomechanical pilot was also conducted to explore the effects on spinal posture and movement behaviour by investigating 3D spinal kinematics during functional tasks.

Results
Preliminary results show that so far, all patients  in the CLASTER group  improved in all measured outcomes, reported high levels of satisfaction, self-efficacy and perceived benefits (Table 2 and 3). The clinicians delivering CLASTER were also highly satisfied with the intervention (Table 3). In addition, early inspection of the biomechanical data indicates a visible change in patients’ spinal posture and movement behaviour post CLASTER, demonstrating greater spinal motion, improved speed, timing and confidence of performing different functional tasks.

Total awarded
£20,000