Interdisciplinary stratified care for low back pain: A qualitative study on the acceptability, potential facilitators and barriers to implementation

Autoři: Carmen Caeiro aff001;  Helena Canhão aff002;  Sofia Paiva aff001;  Luís A. Gomes aff001;  Rita Fernandes aff001;  Ana Maria Rodrigues aff002;  Rute Sousa aff002;  Fernando Pimentel-Santos aff002;  Jaime Branco aff002;  Ana Cristina Fryxell aff003;  Lília Vicente aff003;  Eduardo B. Cruz aff001
Působiště autorů: Physiotherapy Department, Setúbal Polytechnic Institute, Setúbal, Portugal aff001;  EpiDoC Unit, CEDOC, NOVA Medical School, Lisbon, Portugal aff002;  ACES Arrábida, The Regional Health Administration of Lisbon and Tagus Valley, Setúbal, Portugal aff003
Vyšlo v časopise: PLoS ONE 14(11)
Kategorie: Research Article
doi: 10.1371/journal.pone.0225336


Background and objective

The SPLIT project aims to introduce an interdisciplinary stratified model of care for patients with low back pain. This study aimed to explore the acceptability and identify potential barriers and facilitators regarding the upcoming implementation of this project, based on the general practitioners' and physiotherapists' perceptions.


A qualitative study was carried out supported by two focus groups, which were conducted by two researchers. A focus group was carried out with each professional group. One focus group included six general practitioners and the other included six physiotherapists. The focus groups were based on a semi-structured interview schedule, audio-recorded and transcribed verbatim. A thematic analysis was conducted.


The participants explored aspects related to the acceptability of the SPLIT project, emphasising the satisfactory amount of effort that is expected to be required for its implementation. Potential facilitators to the implementation of the model were identified, such as the participants`motivation. Potential barriers were also explored, with particular emphasis on the challenges related to the change of routine care. Lastly, the need for particular adjustments in the health services was also highlighted.


This study`s participants highlighted the feasibility and acceptability of the SPLIT project. The identification of potential barriers and facilitators to its implementation also attained major relevance to better prepare the upcoming implementation of this project. The generalizability of findings to the larger population of relevant practitioners is limited, since only two focus groups were carried out. Therefore, this study`s findings should be considered in terms of transferability to contexts that may have some similarities to the context where the study was carried out.

Klíčová slova:

Health services administration and management – Health services research – Lower back pain – Patients – Physiotherapy – Primary care – Qualitative studies – Treatment guidelines


1. James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2018;392: 1789–1858.

2. Maher C, Underwood M, Buchbinder R. Seminar Non-specific low back pain. The Lancet. 2016; 1–13.

3. Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, et al. Viewpoint Low back pain: a call for action. The Lancet. 2018;391:2384–2388.

4. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Series Low back pain 2. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 2018;391: 2368–2383.

5. Azevedo LF, Costa-Pereira A, Mendonça L, Dias CC, Castro-Lopes JM. Chronic pain and health services utilization: is there overuse of diagnostic tests and inequalities in nonpharmacologic treatment methods utilization? Medical Care. 2013;51(10): 859–869.

6. Branco J, Rodrigues AM, Gouveia N, Eusébio M, Ramiro S, Machado PM, et al. Prevalence of rheumatic and musculoskeletal diseases and their impact on health-related quality of life, physical function and mental health in Portugal: results from EpiReumaPt–a national health survey. RMD Open. 2016;2: e000166. doi: 10.1136/rmdopen-2015-000166 26848402

7. Gouveia N, Rodrigues A, Eusébio M, Ramiro S, Machado P, Canhão H, et al. Prevalence and social burden of active chronic low back pain in the adult Portuguese population: results from a national survey. Rheumatol Int. 2016;36(2): 183–197. doi: 10.1007/s00296-015-3398-7 26661091

8. Cruz EB, Gomes L, Branco JC, Rodrigues A, Fernandes R, Caeiro C, et al. Low back pain chronicity in primary care setting is associated with maladaptive psychosocial factors, other chronic pain condition and high levels of pain at baseline. Ann Rheum Dis. 2019;78: 2088.

9. Ash LM, Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN. Effects of diagnostic information, per se, on patient outcomes in acute radiculopathy and low back pain. AJNR Am J Neuroradiol. 2008;29: 1098–1103. doi: 10.3174/ajnr.A0999 18467522

10. Rutten GM, Degen S, Hendriks EJ, Braspenning JC, Harting J, Oostendorp RA. Adherence to clinical practice guidelines for low back pain in physical therapy: do patients benefit? Physical Therapy. 2010;90(8): 1111–1122. doi: 10.2522/ptj.20090173 20488978

11. Scott NA, Moga C, Harstall C. Managing low back pain in the primary care setting: the know-do gap. Pain Res Managw. 2010;15(6): 392–400.

12. Balagué F, Mannion AF, Pellisé F, Cedraschi C. Seminar Non-specific low back pain. The Lancet. 2012;379: 482–491.

13. Layne EI, Roffey DM, Coyle MJ, Phan P, Kingwell SP, Wai EK. Activities performed and treatments conducted before consultation with a spine surgeon: are patients and clinicians following evidence-based clinical practice guidelines? The Spine Journal. 2018; 18:614–619. doi: 10.1016/j.spinee.2017.08.259 28882524

14. Savigny P, Kuntze S, Watson P, Underwood M, Ritchie G, Cotterell M, et al. Low back pain: early management of persistent non-specific low back pain. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners; 2009 pp. 1–209.

15. National Institute for Health and Care Excellence: Clinical Guidelines. Low back pain and sciatica in over 16s: assessment and management. London: National Institute for Health and Care Excellence. 2016. pp. 1–1067.

16. Foster NE, Hill JC, O’Sullivan P, Hancock M. Stratified models of care. Best Practice & Research Clinical Rheumatology. 2013;27: 649–661.

17. Sowden G, Hill JC, Morso L, Louw Q, Foster NE. Advancing practice for back pain through stratified care (STarT Back). Braz J Phys Ther. 2018;22: 255–64. doi: 10.1016/j.bjpt.2018.06.003 29970301

18. Sowden G, Hill JC, Konstantinou K, Khanna M, Main C, Salmon P, et al. Subgrouping for targeted treatment in primary care for low back pain: the treatment system and clinical training programmes used in the IMPaCT Back study (ISRCTN 55174281) Family Practice. 2011;0: 1–13.

19. Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. The Lancet. 2011;378: 1560–71.

20. Whitehurst DGT, Bryan S, Lewis M, Hill J, Hay EM. Exploring the cost-utility of stratified primary care management for low back pain compared with current best practice within risk-defined subgroups. Ann Rheum Dis. 2012;71: 1796–1802. doi: 10.1136/annrheumdis-2011-200731 22492783

21. Foster NE, Mullis R, Hill JC, Lewis M, Whitehurst DGT, Doyle C, et al. Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison. Ann Fam Med. 2014;12(2): 102–111. doi: 10.1370/afm.1625 24615305

22. Murphy SE, Blake C, Power CK, Fullen BM. The effectiveness of a stratified group intervention using the STarTBack screening tool in patients with LBP—a non randomised controlled trial. BMC Musculoskeletal Disorders. 2013;14: 342. doi: 10.1186/1471-2474-14-342 24308746

23. Raimundo A, Parraça J, Batalha N, Tomas-Carus P, Branco J, Hill J, et al. Portuguese translation, cross-cultural adaptation and reliability of the questionnaire «Start Back Screening Tool» (SBST). Acta Reumatológica Portuguesa. 2017;42: 38–46. 28371572

24. Sanders T, Foster NE, Ong BN. Perceptions of general practitioners towards the use of a new system for treating back pain: a qualitative interview study. BMC Med. 2011;9: 49. doi: 10.1186/1741-7015-9-49 21554696

25. Sanders T, Foster NE, Bishop A, Ong BN. Biopsychosocial care and the physiotherapy encounter: physiotherapists`accounts of back pain consultations. BMC Musculoskeletal Disorders. 2013;14: 65–75. doi: 10.1186/1471-2474-14-65 23421415

26. Karstens S, Joos S, Hill JC, Krug K, Szecsenyi J, Steinhäuser J. General practitioners views of implementing a stratified treatment approach for low back pain in Germany: a qualitative study. PloS ONE. 2015;10(8): e0136119. doi: 10.1371/journal.pone.0136119 26322985

27. Karstens S, Kuithan P, Joos S, Hill JC, Wensing M, Steinhäuser J, et al. Physiotherapists' views of implementing a stratified treatment approach for patients with low back pain in Germany: a qualitative study. BMC Health Serv Res. 2018;18: 214. doi: 10.1186/s12913-018-2991-3 29592802

28. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007;19: 349–357. doi: 10.1093/intqhc/mzm042 17872937

29. Clarke V, Braun V. Teaching thematic analysis: Overcoming challenges and developing strategies for effective learning. The Psychologist. 2013;26(2): 120–123.

30. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3: 77–101.

31. Warwick R, Joseph S, Cordle C, Ashworth P. Social support for women with chronic pelvic pain: what is helpful from whom? Psychology & Health. 2004;19(1): 117–134.

32. Charmaz K, Henwood K. Gounded Theory. In: Willig C, Stainton-Rogers W, editors. The sage handbook of qualitative research in psychology. London: SAGE Publications; 2008. pp. 240–260.

33. Barros P, Machado S, Simões J. Portugal: Health system review. Health Syst Transit. 2011;13(4): 1–156. 22222781

34. Simões JA, Augusto GF, Fronteira I, Hernández-Quevedo C. Portugal: Health system review. Health Syst Transit. 2017;19(2):1–211. 28485714

35. Sousa P, Uva AS, Serranheira F, Pinto F, Øvretveit J. The patient safety journey in Portugal: challenges and opportunities from a public health perspective. Revista Portuguesa de Saúde Pública [Portuguese Journal of Public Health]. 2009;(Nº especial 25 anos RPSP [Special number—25 years of RPSP]): 91–106.

36. Fernandes JV. Um duplo desafio: organização e modernidade [A double challenge: organisation and modernity]. In: Fernandes JV, Barros PP, Fernandes AC, editors. Três olhares sobre o futuro da saúde em Portugal [Three different perspectives regarding the future of health in Portugal]. Cascais: PRINCIPIA; 2011. pp. 15–49.

37. Monteiro S. Reconfigurações na Saúde [Restructuring Health]. In: Carmo I, Fernandes AC, Justo C, Sakellarides C, Nunes JA, Silva JA, et al., editors. Serviço Nacional de Saúde em Portugal As ameaças, a crise e os desafios [Potuguese National Health Services The threats, crisis and challenges]. Coimbra: Edições Almedina, S.A; 2012. pp. 43–46.

38. ARSLVT Núcleo de Estudos e Planeamento. ACES Arrábida, Caracterização e Propostas de Reestruturação [ACES Arrábida, Characterization and Proposals for Reorganization]. 2015 pp. 1–15.

39. Andreazza R. Narrativas dos caminhos dos cidadãos portugueses no Serviço Nacional de Saúde [Portuguese`s narratives of their journeys in the National Health Services]. In: Carapinheiro G, Correia T, editors. Novos temas de saúde, novas questões sociais [New topics in health, new social questions]. Lisbon: Mundos Sociais; 2015. pp. 99–104.

40. Castro-Lopes J, Romão P, Paiva MM. A Dor Crónica em Portugal [Chronic Pain in Portugal]. Pain Proposal; 2010. pp. 1–12.

41. Flick U. Focus groups. In: An introduction to qualitative research. 4th ed. Sage: 2009. pp. 194–209.

42. Finch H, Lewis J, Turley C. Focus groups. In: Ritchie J, Lewis J, Nicholls CM, Ormston R, editors. Qualitative Research Practice. 2nd ed. Sage; 2014. pp. 211–42.

43. Krueger RA, Casey AC. Developing a questioning route. In: Focus groups: a pratical guide for applied research. London: SAGE Publications; 2015. pp. 39–76.

44. Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, et al. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med. 2010; 8: 63. doi: 10.1186/1741-7015-8-63 20961442

45. Busetto L, Luijkx K, Calciolari S, Ortiz LGG, Vrijhoef HJM. Barriers and facilitators to workforce changes in integrated care. Int J Integr Care. 2018 Jun 1;18(2): 17. doi: 10.5334/ijic.3587 30127701

46. Briggs AM, Towler SCB, Speerin R, March LM. Models of care for musculoskeletal health in Australia: now more than ever to drive evidence into health policy and practice. Aust Health Rev. 2014;38: 401–405. doi: 10.1071/AH14032 25086678

47. Dziedzic KS, French S, Davis AM, Geelhoed E, Porcheret M. Implementation of musculoskeletal models of care in primary care settings: theory, practice, evaluation and outcomes for musculoskeletal health in high-income economies. Best Practice & Research Clinical Rheumatology. 2016;30: 375–397.

48. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017;17: 88. doi: 10.1186/s12913-017-2031-8 28126032

49. Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Adm Policy Ment Health. 2009 Jan;36(1): 24–34. doi: 10.1007/s10488-008-0197-4 19104929

50. Correia T, Carapinheiro G, Silva J, Vieira J. O sistema de saúde português no tempo da troika: a experiência dos médicos [The Portuguese National Health Services and the TROIKA: the physicians`experiences]. Lisbon: ISCTE—Instituto Universitário de Lisboa/Ordem dos Médicos; 2015 pp. 1–36.

51. Lau R, Stevenson F, Ong BN, Dziedzic K, Treweek S, Eldridge S, et al. Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews. Implement Sci. 2016;11: 40. doi: 10.1186/s13012-016-0396-4 27001107

52. Grant A. The use of qualitative research methodologies within musculoskeletal physiotherapy practice. Manual Therapy. 2005;10(1): 1–3. doi: 10.1016/j.math.2004.07.001 15681262

53. Johnson R, Waterfield J. Making words count: the value of qualitative research. Physiother Res Int. 2004;9(3):121–131. doi: 10.1002/pri.312 15560669

54. Treharne GJ, Riggs DW. Ensuring Quality in Qualitative Research. In: Qualitative Research in Clinical and Health Psychology. London: Macmillan Education UK; 2015. pp. 57–73.

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2019 Číslo 11