Abstract
BackgroundSciatica is common and associated with significant impacts for the individual and society. The SCOPiC randomised controlled trial (RCT) (trial registration: ISRCTN75449581) tested stratified primary care for sciatica by subgrouping patients into one of three groups based on prognostic and clinical indicators. Patients in one group were ‘fast-tracked’ for a magnetic resonance imaging (MRI) scan and spinal specialist opinion. This paper reports qualitative research exploring patients’ and clinicians’ perspectives on the acceptability of this ‘fast-track’ pathway.MethodsSemi-structured interviews were conducted with 20 patients and 20 clinicians (general practitioners, spinal specialist physiotherapists, spinal surgeons). Data were analysed thematically and findings explored using Normalisation Process Theory (NPT) and ‘boundary objects’ concept.ResultsWhilst the ‘fast-track’ pathway achieved a degree of ‘coherence’ (i.e. made sense) to both patients and clinicians, particularly in relation to providing early reassurance based on MRI scan findings, it was less ‘meaningful’ to some clinicians for managing patients with acute symptoms, reflecting a reluctance to move away from the usual ‘stepped care’ approach. Both groups felt a key limitation of the pathway was that it did not shorten patient waiting times between their spinal specialist consultation and further treatments.ConclusionFindings contribute new knowledge about patients’ and clinicians’ perspectives on the role of imaging and spinal specialist opinion in the management of sciatica, and provide important insights for understanding the ‘fast-track’ pathway, as part of the stratified care model tested in the RCT.Future research into the early referral of patients with sciatica for investigation and specialist opinion should include strategies to support clinician behaviour change; as well as take into account the role of imaging in providing reassurance to patients with severe symptoms in cases where imaging reveals a clear explanation for the patient’s pain, and where this is accompanied by a thorough explanation from a trusted clinical expert.
Highlights
Sciatica is common and associated with significant impacts for the individual and society
This paper reports on the findings from nested qualitative research that aimed to understand the acceptability of the ‘fast-track’ pathway to patients and clinicians, i.e. general practitioners (GPs), spinal specialist physiotherapists and spinal surgeons
Exploring the identified themes in relation to normalisation process theory (NPT) and the ‘boundary object’ concept The findings presented indicate that all groups perceived benefit from the ‘fast-track’ care pathway to magnetic resonance imaging (MRI) scan and spinal specialist consultation in the stratified care approach tested in the SCiatica Outcomes in Primary Care (SCOPiC) trial; both in relation to clinical outcomes and in providing reassurance to patients based on MRI scans
Summary
Sciatica is common and associated with significant impacts for the individual and society. Patients in one group were ‘fast-tracked’ for a magnetic resonance imaging (MRI) scan and spinal specialist opinion. Sciatica is a common form of low back pain (LBP) characterised by pain radiating into the leg [1]. Sciatica is often experienced as acute symptoms resolving over several weeks or months, either naturally or with treatment; up to 30% of people will still experience pain after a year [1]. When compared to LBP alone, patients with sciatica have worse pain and disability, poorer quality of life and use more healthcare resources [3, 4]. Current usual clinical management for most patients with sciatica follows a ‘stepped’ care approach, with initial conservative management in primary care comprising low-intensity treatments (e.g. advice and education, ‘wait-and-see’ approaches, pain medications), before moving to more intensive treatments (e.g. courses of physiotherapy) if symptoms persist. Patients whose symptoms still fail to improve are referred to specialist spinal services for investigations and consideration for more invasive treatments such as spinal injections and surgery
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