University of Oulu

Simula, A.S., Malmivaara, A., Booth, N. et al. A classification-based approach to low back pain in primary care – protocol for a benchmarking controlled trial. BMC Fam Pract 21, 61 (2020).

A classification-based approach to low back pain in primary care : protocol for a benchmarking controlled trial

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Author: Simula, A. S.1,2; Malmivaara, A.3; Booth, N.4;
Organizations: 1Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
2Department of General Medicine, The South Savo Social and Health Care Authority, Mikkeli, Finland
3Centre for Health and Social Economics, Finnish Institute for Health and Welfare, Helsinki, Finland
4Faculty of Social Sciences (Health Sciences), Tampere University, Tampere, Finland
5Finnish Institute of Occupational Health, Oulu, Finland
Format: article
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 0.8 MB)
Persistent link:
Language: English
Published: Springer Nature, 2020
Publish Date: 2020-06-23


Background: Guidelines recommend a biopsychosocial framework for low back pain (LBP) management and the avoidance of inappropriate imaging. In clinical practice, care strategies are often inconsistent with evidence and guidelines, even though LBP is the most common disabling health condition worldwide. Unhelpful beliefs, attitudes and inappropriate imaging are common. LBP is understood to be a complex biopsychosocial phenomenon with many known multidimensional risk factors (symptom- and lifestyle-related, psychological and social) for persistent or prolonged disability, which should be identified and addressed by treatment. The STarT Back Tool (SBT) was developed for early identification of individual risk factors of LBP to enable targeted care. Stratified care according SBT has been shown to improve the effectiveness of care in a primary care setting. A biopsychosocially-oriented patient education booklet, which includes imaging guidelines and information, is one possible way to increase patients’ understanding of LBP and to reduce inappropriate imaging. Premeditated pathways, education of professionals, written material, and electronic patient registry support in health care organizations could help implement evidence-based care.

Methods: We will use a Benchmarking Controlled Trial (BCT) design in our study. We will prospectively collect data from three health care regions before and after the implementation of a classification-based approach to LBP in primary care. The primary outcome will be change in PROMIS (Patient-Reported Outcomes Measurement Information System) (short form 20a) over 12-month follow-up.

Discussion: The implementation of a classification-based biopsychosocial approach can potentially improve the care of LBP patients, reduce inappropriate imaging without increasing health-care costs, and decrease indirect costs by reducing work disability. Using the BCT we will be able to evaluate the effectiveness of the improvement strategy for the entire care pathway.

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Series: BMC family practice
ISSN: 1471-2296
ISSN-E: 1471-2296
ISSN-L: 1471-2296
Volume: 21
Article number: 6
DOI: 10.1186/s12875-020-01135-8
Type of Publication: A1 Journal article – refereed
Field of Science: 3121 General medicine, internal medicine and other clinical medicine
Funding: The study is funded by: The Finnish Cultural Foundation; The South Savo social and health care authority (ESSOTE), Mikkeli, Finland; and State research funding, The Northern Ostrobothnia Hospital District, Oulu, Finland. The Finnish Cultural Foundation and a State Research Funding body peer reviewed the study as part of applications for funding.
Copyright information: © The Author(s). 2020. Open Access. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.