Usual Care Better than Stratified Care for Sciatica

Kika Konstantinou, PhD

Investigators did not find convincing evidence to support the use of a stratified care model in improving sciatica symptoms more quickly than usual care.

In fact, the stratified care model for patients with sciatica consulting in primary care was not better than usual care for clinical or health economic outcomes. Thus, the results did not support transitioning to such a care model.

Kika Konstantinou, PhD, and colleagues conducted a two-parallel-arm, pragmatic, randomized controlled trial to investigate the clinical and cost-effectiveness of stratified care versus non-stratified usual care for patients presenting with sciatica in primary care. Stratified care has resulted in better outcomes among patients with non-specific low back pain, but the team wanted to test the care on sciatica.

The trial was completed at 3 centers in the UK. Patients were eligible if they were at least 18 years old, had a clinical diagnosis of sciatica, had access to a phone, were not pregnant, were not currently receiving treatment for the same problem, and had no previous spinal surgery.

A sciatica case was defined based on an assessing physiotherapist being at least 70% confident in their clinical diagnosis. Patients with sciatica had at least 1 of the following: leg pain approximating a dermatomal distribution; leg pain worse than or as bad as back pain; leg pain worse with coughing, sneezing, or straining; and subjective sensory changes approximating a dermatomal distribution. They also could have had objective neurological deficits indicative of nerve root compression, a positive neural tension test, or leg pain worse with weight-bearing activities and better with sitting.

Patients were randomly assigned to either stratified or usual care. In the stratified care group, an algorithm allocated patients to 1 of 3 groups. Those in the first group were expected to do well and were offered brief advice and support in up to 2 physiotherapy sessions. In group 2, patients were offered up to 6 physiotherapy sessions, while group 3 was fast-tracked to MRI and spinal specialist assessment within 4 weeks of randomization.

For patients in the usual care cohort, they had a consultation at their general practice, along with a consultation with a physiotherapist at the SCOPiC research clinic. These patients had their care planned without the use of stratification tools and referrals for further treatment were made at the discretion of the assessing physiotherapist.

The primary outcome of the study was time to first resolution of sciatica symptoms defined as either much better or completely recovered based on a six-point ordinal scale. Additional outcomes included global perceived change, general health, neuropathic pain symptoms, days lost from work and productivity loss due to sciatica, and satisfaction with care.

Overall, the team randomly assigned 476 patients from 42 general practices to stratified or usual care—238 patients in each arm. For time to resolution of sciatica symptoms, the overall response rate was 89% (88% in the stratified care arm vs 90% in the usual care arm). The median time to symptom resolution was 10 weeks (995% CI, 6.4-13.6) in the stratified care arm and 12 weeks (95% CI, 9.4-14.6) in the usual care arm. A survival analysis showed no significant difference between the arms (HR, 1.14; 95% CI, .89-1.46).

Compared to usual care, stratified care was not cost-effective.

Konstantinou and the team concluded the results did not support a transition to such a model of stratified care. Future research is needed to identify factors that predict the outcome or treatment response in patients with sciatica to inform new models of stratified care.

The study, “Stratified care versus usual care for management of patients presenting with sciatica in primary care (SCOPiC): a randomised controlled trial,” was published online in The Lancet Rheumatology.