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Croft P, Hill JC, Foster NE, Dunn KM, van der Windt DA. Stratified health care for low back pain using the STarT Back approach: Holy Grail or doomed to fail? Pain 2024:00006396-990000000-00658. [PMID: 39037849 DOI: 10.1097/j.pain.0000000000003319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 05/23/2024] [Indexed: 07/24/2024]
Abstract
ABSTRACT There have been at least 7 separate randomised controlled trials published between 2011 and 2023 that have examined primary care for nonspecific low back pain informed by the STarT Back approach to stratified care based on risk prediction, compared with care not informed by this approach. The results, across 4 countries, have been contrasting-some demonstrating effectiveness and/or efficiency of this approach, others finding no benefits over comparison interventions. This review considers possible explanations for the differences, particularly whether this is related to poor predictive performance of the STarT Back risk-prediction tool or to variable degrees of success in implementing the whole STarT Back approach (subgrouping and matching treatments to predicted risk of poor outcomes) in different healthcare systems. The review concludes that although there is room for improving and expanding the predictive value of the STarT Back tool, its performance in allocating individuals to their appropriate risk categories cannot alone explain the variation in results of the trials to date. Rather, the learning thus far suggests that challenges in implementing stratified care in clinical practice and in changing professional practice largely explain the contrasting trial results. The review makes recommendations for future research, including greater focus on studying facilitators of implementation of stratified care and developing better treatments for patients with nonspecific low back pain at high risk of poor outcomes.
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Affiliation(s)
- Peter Croft
- School of Medicine, Primary Care Centre Versus Arthritis, Keele University, Keele, United Kingdom
| | - Jonathan C Hill
- School of Medicine, Primary Care Centre Versus Arthritis, Keele University, Keele, United Kingdom
| | - Nadine E Foster
- School of Medicine, Primary Care Centre Versus Arthritis, Keele University, Keele, United Kingdom
- STARS Education and Research Alliance, Surgical Treatment and Rehabilitation Service (STARS), The University of Queensland and Metro North Health, Brisbane, Queensland, Australia
| | - Kate M Dunn
- School of Medicine, Primary Care Centre Versus Arthritis, Keele University, Keele, United Kingdom
| | - Danielle A van der Windt
- School of Medicine, Primary Care Centre Versus Arthritis, Keele University, Keele, United Kingdom
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Ampiah PK, Hendrick P, Moffatt F, Ampiah JA. Barriers and facilitators to the delivery of a biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana. A qualitative study. Disabil Rehabil 2024:1-11. [PMID: 38963089 DOI: 10.1080/09638288.2024.2374497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 06/26/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE Low back pain management has evolved with researchers advocating for a biopsychosocial management model. The biopsychosocial management model has been predominantly applied in high-income countries and underexplored in low- and middle-income countries including Ghana. This study aimed to explore the potential barriers and facilitators to patients with chronic low back pain (CLBP) and physiotherapists engagement with a biopsychosocial intervention (exercise and patient education) as part of a feasibility study. MATERIAL AND METHODS This was a qualitative study embedded within a mixed-methods, sequential, feasibility study, in Ghana, applying semi-structured interviews. Two categories of participants involved in this study were, two trained physiotherapists, and six patients with CLBP, sampled within the feasibility study. RESULTS Regarding the barriers and facilitators to the delivery of the BPS intervention, five interlinked themes emerged from the thematic analysis. These were: structure and process of delivery; patients' expectations; patients' health beliefs, autonomy, and engagement; external influences and personal and professional characteristics of physiotherapists. CONCLUSION The themes that emerged from this study demonstrated many positive facilitators based on participants' improved understanding of LBP and the clarity and purpose of the biopsychosocial intervention. The results therefore demonstrate a potential to deliver the biopsychosocial intervention in a Ghanaian context.
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Affiliation(s)
- Paapa Kwesi Ampiah
- Department of Health Sciences, College of Health, Medicine and Life Sciences, Brunel University London, UK
| | - Paul Hendrick
- Department of Physiotherapy and Rehabilitation Sciences, School of Health Sciences, University of Nottingham, UK
| | - Fiona Moffatt
- Department of Physiotherapy and Rehabilitation Sciences, School of Health Sciences, University of Nottingham, UK
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Duarte ST, Moniz A, Costa D, Donato H, Heleno B, Aguiar P, Cruz EB. Low back pain management in primary healthcare: findings from a scoping review on models of care. BMJ Open 2024; 14:e079276. [PMID: 38754873 PMCID: PMC11097853 DOI: 10.1136/bmjopen-2023-079276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Models of care (MoCs) describe evidence-informed healthcare that should be delivered to patients. Several MoCs have been implemented for low back pain (LBP) to reduce evidence-to-practice gaps and increase the effectiveness and sustainability of healthcare services. OBJECTIVE To synthesise research evidence regarding core characteristics and key common elements of MoCs implemented in primary healthcare for the management of LBP. DESIGN Scoping review. DATA SOURCES Searches on MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science and grey literature databases were conducted. ELIGIBILITY CRITERIA Eligible records included MoCs implemented for adult LBP patients in primary healthcare settings. DATA EXTRACTION AND SYNTHESIS Data extraction was carried out independently by two researchers and included a summary of the studies, the identification of the MoCs and respective key elements, concerning levels of care, settings, health professionals involved, type of care delivered and core components of the interventions. Findings were investigated through a descriptive qualitative content analysis using a deductive approach. RESULTS 29 studies reporting 11 MoCs were included. All MoCs were implemented in high-income countries and had clear objectives. Ten MoCs included a stratified care approach. The assessment of LBP patients typically occurred in primary healthcare while care delivery usually took place in community-based settings or outpatient clinics. Care provided by general practitioners and physiotherapists was reported in all MoCs. Education (n=10) and exercise (n=9) were the most common health interventions. However, intervention content, follow-ups and discharge criteria were not fully reported. CONCLUSIONS This study examines the features of MoCs for LBP, highlighting that research is in its early stages and stressing the need for better reporting to fill gaps in care delivery and implementation. This knowledge is crucial for researchers, clinicians and decision-makers in assessing the applicability and transferability of MoCs to primary healthcare settings.
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Affiliation(s)
- Susana Tinoco Duarte
- Comprehensive Health Research Centre, NOVA National School of Public Health - NOVA University Lisbon, Lisboa, Portugal
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
| | - Alexandre Moniz
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Comprehensive Health Research Centre, NOVA Medical School | Faculdade de Ciências Médicas, NMS | FCM - NOVA University Lisbon, Lisboa, Portugal
| | - Daniela Costa
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Department of Physiotherapy, Escola Superior de Saúde do Alcoitão, Alcabideche, Portugal
| | - Helena Donato
- Documentation and Scientific Information Service, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
- University of Coimbra Faculty of Medicine, Coimbra, Portugal
| | - Bruno Heleno
- Comprehensive Health Research Centre, NOVA Medical School | Faculdade de Ciências Médicas, NMS | FCM - NOVA University Lisbon, Lisboa, Portugal
| | - Pedro Aguiar
- Comprehensive Health Research Centre, NOVA National School of Public Health - NOVA University Lisbon, Lisboa, Portugal
| | - Eduardo B Cruz
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Comprehensive Health Research Centre, NOVA University Lisbon, Lisboa, Portugal
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Gomes LA, Fernandes R, Caeiro C, Henriques AR, de Sousa RD, Branco JC, Pimentel-Santos F, Moniz R, Vicente L, Canhão H, Rodrigues AM, Cruz EB. A Stratified Approach for Managing Patients With Low Back Pain in Primary Care (SPLIT Program): A Before-and-After Study. Ann Fam Med 2024; 22:195-202. [PMID: 38806277 PMCID: PMC11237233 DOI: 10.1370/afm.3104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 01/29/2024] [Accepted: 02/02/2024] [Indexed: 05/30/2024] Open
Abstract
PURPOSE To determine the effects of stratified primary care for low back pain (SPLIT program) in decreasing back-related disability for patients with low back pain (LBP) in primary care. METHODS We conducted a before-and-after study. We compared health-related outcomes for 2 sequential, independent cohorts of patients with LBP recruited at 7 primary care units in Portugal. The first prospective cohort study characterized usual care (UC) and collected data from February to September 2018. The second was performed when the SPLIT program was implemented and collected data from November 2018 to October 2021. Between cohorts, physical therapists were trained in the implementation of the SPLIT program, which used the STarT Back Screening Tool to categorize patients for matched treatment. We compared back-related disability (Roland-Morris Disability Questionnaire, 0-24 points), pain (Numeric Pain Rating Scale, 0-10 points), perceived effect of treatment (Global Perceived Effect Scale, -5 to +5 points), and health-related quality of life (EuroQoL 5 dimensions 3 levels index, 0-1 points). RESULTS We enrolled a total of 447 patients: 115 in the UC cohort (mostly treated with pharmacologic treatment) and 332 in the SPLIT cohort (all referred for a physical therapy intervention program). Over the study period of 6 months, patients in the SPLIT program showed significantly greater improvements in back-related disability (ß, -2.94; 95% CI, -3.63 to -2.24; P ≤ .001), pain (ß, -0.88; 95% CI, -1.18 to -0.57; P ≤ .001), perceived effect of treatment (ß, 1.40; 95% CI, 0.97 to 1.82; P ≤ .001), and health-related quality of life (ß, 0.11; 95% CI, 0.08 to 0.14; P ≤ .001) compared with UC. CONCLUSIONS Patients in the SPLIT program for LBP showed greater benefits regarding health-related outcomes than those receiving UC.
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Affiliation(s)
- Luís Antunes Gomes
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- EpiDoC Unit, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- Departamento de Fisioterapia, Escola Superior de Saúde, Instituto Politécnico de Setúbal, Setubal, Portugal
| | - Rita Fernandes
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- Departamento de Fisioterapia, Escola Superior de Saúde, Instituto Politécnico de Setúbal, Setubal, Portugal
| | - Carmen Caeiro
- Departamento de Fisioterapia, Escola Superior de Saúde, Instituto Politécnico de Setúbal, Setubal, Portugal
| | - Ana Rita Henriques
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- EpiDoC Unit, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Rute Dinis de Sousa
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- EpiDoC Unit, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Jaime C Branco
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- EpiDoC Unit, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- Serviço de Reumatologia do Hospital Egas Moniz - Centro Hospitalar Lisboa Ocidental (CHLO-EPE), Lisbon, Portugal
| | - Fernando Pimentel-Santos
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- Serviço de Reumatologia do Hospital Egas Moniz - Centro Hospitalar Lisboa Ocidental (CHLO-EPE), Lisbon, Portugal
| | - Rubina Moniz
- Departamento de Fisioterapia, Escola Superior de Saúde, Instituto Politécnico de Setúbal, Setubal, Portugal
- Agrupamento de Centros de Saúde da Arrábida - Administração Regional de Saúde de Lisboa e Vale do Tejo (ACeS Arrábida - ARSLVT), Setúbal, Portugal
| | - Lilia Vicente
- Agrupamento de Centros de Saúde da Arrábida - Administração Regional de Saúde de Lisboa e Vale do Tejo (ACeS Arrábida - ARSLVT), Setúbal, Portugal
| | - Helena Canhão
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- EpiDoC Unit, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- Unidade de Reumatologia, Centro Hospitalar Universitário Lisboa Central - Hospital Santo António dos Capuchos (CHULC-EPE), Lisbon, Portugal
| | - Ana Maria Rodrigues
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- EpiDoC Unit, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- Unidade de Reumatologia, Hospital dos Lusíadas, Lisbon, Portugal
| | - Eduardo Brazete Cruz
- Comprehensive Health Research Centre (CHRC), NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- Departamento de Fisioterapia, Escola Superior de Saúde, Instituto Politécnico de Setúbal, Setubal, Portugal
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Simpson P, Holopainen R, Schütze R, O'Sullivan P, Smith A, Kent P. Becoming confidently competent: a qualitative investigation of training in cognitive functional therapy for persistent low back pain. Physiother Theory Pract 2024; 40:804-816. [PMID: 36420994 DOI: 10.1080/09593985.2022.2151333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 11/05/2022] [Accepted: 11/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Physiotherapists trained to deliver biopsychosocial interventions for complex musculoskeletal pain problems often report difficulties in confidence and competency at the end of training. Cognitive Functional Therapy (CFT) is an individualized biopsychosocial intervention and understanding the facilitators and barriers to training in CFT will help inform future training programs. This study aimed to explore physiotherapists' and trainers' perceptions of the process of developing competency in CFT. METHODS A cross-sectional qualitative design using interviews of 18 physiotherapists and two trainers investigated training in CFT for persistent LBP via reflexive thematic analysis. RESULTS Physiotherapists reported undergoing a complex behavior change process during training. Four themes emerged: 1) Pre-training factors; 2) Behavior change process; 3) Physiotherapy culture and context; and 4) Confident competence and beyond. Key components included graduated practice exposure linked to experiential learning with feedback and clear competency guidelines. Pre-training and contextual factors were facilitators or barriers depending on the individual. Physiotherapists supported ongoing learning, even after competency was achieved. CONCLUSIONS This study provides insight into the processes of change during progress toward competency in CFT. It highlights facilitators and barriers to competency including physiotherapy culture and the clinical environment. The study also describes important educational components, including experiential learning and clinical integration, which may be used to inform future post-graduate training.
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Affiliation(s)
- Phoebe Simpson
- School of Allied Health, Curtin University, Perth, Australia
| | - Riikka Holopainen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylän, Finland
| | - Robert Schütze
- School of Allied Health, Curtin University, Perth, Australia
- Multidisciplinary Pain Management Centre, Royal Perth Hospital, Victoria Square, Perth, Australia
| | - Peter O'Sullivan
- School of Allied Health, Curtin University, Perth, Australia
- Bodylogic Physiotherapy, Perth, Australia
| | - Anne Smith
- School of Allied Health, Curtin University, Perth, Australia
| | - Peter Kent
- School of Allied Health, Curtin University, Perth, Australia
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George SZ. Lost in implementation: risk stratified care for musculoskeletal pain. Pain 2023; 164:2137-2138. [PMID: 37318014 PMCID: PMC10524318 DOI: 10.1097/j.pain.0000000000002939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham, NC, United States
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Lapin B, Li Y, Davin S, Stilphen M, Johnson JK, Benzel E, Habboub G, Katzan IL. Comparison of stratification techniques for optimal management of patients with chronic low back pain in spine clinics. Spine J 2023; 23:1334-1344. [PMID: 37149152 DOI: 10.1016/j.spinee.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/27/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND CONTEXT Identifying optimal stratification techniques for subgrouping patients with low back pain (LBP) into treatment groups for the purpose of identifying optimal management and improving clinical outcomes is an important area for further research. PURPOSE Our study aimed to compare performance of the STarT Back Tool (SBT) and 3 stratification techniques involving PROMIS domain scores for use in patients presenting to a spine clinic for chronic LBP. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE Adult patients with chronic LBP seen in a spine center between November 14, 2018 and May 14, 2019 who completed patient-reported outcomes (PROs) as part of routine care, and were followed up with completed PROs 1 year later. OUTCOME MEASURES Four stratification techniques, including SBT, and 3 PROMIS-based techniques: the NIH Task Force recommended Impact Stratification Score (ISS), symptom clusters based on latent class analysis (LCA), and SPADE symptom clusters. METHODS The 4 stratification techniques were compared according to criterion validity, construct validity, and prognostic utility. For criterion validity, overlap in characterization of mild, moderate, and severe subgroups were compared to SBT, which was considered the gold standard, using quadratic weighted kappa statistic. Construct validity compared techniques' ability to differentiate across disability groups defined by modified Oswestry LBP Disability Questionnaire (MDQ), median days in the past month unable to complete activities of daily living (ADLs), and worker's compensation using standardized mean differences (SMD). Prognostic utility was compared based on the techniques' ability to predict long-term improvement in outcomes, defined as improvement in global health and MDQ at 1-year. RESULTS There were 2,246 adult patients with chronic LBP included in our study (mean age 61.0 [SD 14.0], 55.0% female, 83.4% white). All stratification techniques resulted in roughly a third of patients grouped into mild, moderate, and severe categories, with ISS and LCA demonstrating substantial agreement with SBT, while SPADE had moderate agreement. Construct validity was met for all techniques, with large effects demonstrated between mild and severe categories for differentiating MDQ, ADLs, and worker's compensation disability groups (SMD range 0.57-2.48). All stratification techniques demonstrated ability to detect improvement by 1-year, with severe groups experiencing the greatest improvement in multivariable logistic regression models. CONCLUSIONS All 4 stratification techniques demonstrated validity and prognostic utility for subgrouping patients with chronic LBP based on risk of long-term disability. ISS and LCA symptom clusters may be the optimal methods given the improved feasibility of including only a few relevant PROMIS domains. Future research should investigate multidisciplinary treatment approaches to target mild, moderate, and severe patients based on these techniques.
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Affiliation(s)
- Brittany Lapin
- Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA.
| | - Yadi Li
- Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
| | - Sara Davin
- Center for Spine Health, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
| | - Mary Stilphen
- Department of Rehabilitation and Sports Therapy, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
| | - Joshua K Johnson
- Department of Rehabilitation and Sports Therapy, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA; Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA; Center for Value-Based Care Research, Community Care, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
| | - Edward Benzel
- Center for Spine Health, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
| | - Ghaith Habboub
- Center for Spine Health, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
| | - Irene L Katzan
- Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, JJ3-603, Cleveland, OH 44195, USA
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Rhon DI, Greenlee TA, Poehlein E, Beneciuk JM, Green CL, Hando BR, Childs JD, George SZ. Effect of Risk-Stratified Care on Disability Among Adults With Low Back Pain Treated in the Military Health System: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2321929. [PMID: 37410465 PMCID: PMC10326636 DOI: 10.1001/jamanetworkopen.2023.21929] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/19/2023] [Indexed: 07/07/2023] Open
Abstract
Importance Tailored treatments for low back pain (LBP) based on stratifying risk for poor prognosis have emerged as a promising approach to improve quality of care, but they have not been validated in trials at the level of individual randomization in US health systems. Objective To assess the clinical effectiveness of risk-stratified vs usual care on disability at 1 year among patients with LBP. Design, Setting, and Participants This parallel-group randomized clinical trial enrolled adults (ages 18-50 years) seeking care for LBP with any duration in primary care clinics within the Military Health System from April 2017 to February 2020. Data analysis was conducted from January to December 2022. Interventions Risk-stratified care, in which participants received physiotherapy treatment tailored for their risk category (low, medium, or high), or usual care, in which care was determined by participants' general practitioners and may have included a referral to physiotherapy. Main Outcomes and Measures The primary outcome was the Roland Morris Disability Questionnaire (RMDQ) score at 1 year, with planned secondary outcomes of Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) and Physical Function (PF) scores. Raw downstream health care utilization was also reported within each group. Results Analysis included 270 participants (99 [34.1%] female participants; mean [SD] age, 34.1 [8.5] years). Only 21 patients (7.2%) were classified as high risk. Neither group was superior on the RMDQ (least squares [LS] mean ratio of risk-stratified vs usual care: 1.00; 95% CI, 0.80 to 1.26), the PROMIS PI (LS mean difference, -0.75 points; 95% CI -2.61 to 1.11 points), or the PROMIS PF (LS mean difference, 0.05 points; 95% CI, -1.66 to 1.76 points). Conclusions and Relevance In this randomized clinical trial, using risk stratification to categorize and provide tailored treatment for patients with LBP did not result in better outcomes at 1 year compared with usual care. Trial Registration ClinicalTrials.gov Identifier: NCT03127826.
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Affiliation(s)
- Daniel I. Rhon
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
- Department of Rehabilitation Medicine, Uniformed Services University, Bethesda, Maryland
| | - Tina A. Greenlee
- Department of Rehabilitation Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
| | - Emily Poehlein
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Jason M. Beneciuk
- Department of Physical Therapy, College of Public Health & Health Professions, University of Florida, Gainesville
- Brooks Rehabilitation Clinical Research Center, Jacksonville, Florida
| | - Cynthia L. Green
- Department of Biostatistics and Bioinformatics and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Ben R. Hando
- Department of Orthopaedics and Rehabilitation, Wilford Hall Ambulatory Surgical Center, JBSA Lackland, Texas
| | | | - Steven Z. George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, School of Medicine, Durham, North Carolina
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Main CJ, Simon CB, Beneciuk JM, Greco CM, George SZ, Ballengee LA. The Psychologically Informed Practice Consultation Roadmap: A Clinical Implementation Strategy. Phys Ther 2023; 103:pzad048. [PMID: 37158465 PMCID: PMC10390080 DOI: 10.1093/ptj/pzad048] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/28/2023] [Accepted: 05/08/2023] [Indexed: 05/10/2023]
Abstract
Psychologically informed practice (PiP) includes a special focus on psychosocial obstacles to recovery, but research trials have revealed significant difficulties in implementing PiP outside of research environments. Qualitative studies have identified problems of both competence and confidence in tackling the psychosocial aspects of care, with a tendency to prefer dealing with the more mechanical aspects of care. In PiP, the distinction between assessment and management is not clear-cut. Analysis of the problem is part of the intervention, and guided self-management begins with the initial detective work by the patient, who is encouraged to develop successful and relevant behavior change. This requires a different style and focus of communication that some clinicians find difficult to enact. In this Perspective, the PiP Consultation Roadmap is offered as a guide for clinical implementation to establish a therapeutic relationship, develop patient-centered communication, and guide effective pain self-management. These strategies are illustrated through the metaphor of the patient learning to drive, with the therapist as a driving instructor and the patient as a student driver. For convenience, the Roadmap is depicted in 7 stages. Each stage represents aspects of the clinical consultation in a recommended order, although the Roadmap should be viewed as a general guide with a degree of flexibility to accommodate individual differences and optimize PiP interventions. It is anticipated that the experienced PiP clinician will find it progressively easier to implement the Roadmap as the building blocks and style of consultation become more familiar.
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Affiliation(s)
- Chris J Main
- School of Medicine, Keele University, Newcastle, UK
| | - Corey B Simon
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jason M Beneciuk
- Department of Physical Therapy, University of Florida, Gainesville, Florida, USA
- Brooks Rehabilitation, Jacksonville, Florida, USA
| | - Carol M Greco
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Physical Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences Pittsburgh, Pennsylvania, USA
| | - Steven Z George
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Lindsay A Ballengee
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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10
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Are we giving stratified care a fair trial? J Physiother 2023; 69:65-67. [PMID: 36914522 DOI: 10.1016/j.jphys.2023.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/13/2023] [Accepted: 02/24/2023] [Indexed: 03/16/2023] Open
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Saunders B, Chudyk A, Protheroe J, Cooper V, Bartlam B, Birkinshaw H, Foster NE, Hill JC. Risk-based stratified primary care for common musculoskeletal pain presentations: qualitative findings from the STarT MSK cluster randomised controlled trial. BMC PRIMARY CARE 2022; 23:326. [PMID: 36522640 PMCID: PMC9754991 DOI: 10.1186/s12875-022-01924-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The STarT MSK cluster randomised controlled trial (RCT) investigated the clinical- and cost-effectiveness of risk-based stratified primary care versus usual care for patients with back, neck, shoulder, knee or multi-site pain. Trial quantitative results showed risk-based stratified care was not superior to usual care for patients' clinical outcomes, but the intervention led to some changes in GP clinical decision-making. This paper reports a linked qualitative study exploring how risk-based stratified care was perceived and used in the trial, from the perspectives of clinicians and patients. METHODS Semi-structured interviews were conducted with 27 patients, and focus groups and interviews with 20 clinicians (GPs and physiotherapists) in the intervention arm of the trial. Data were analysed thematically and findings explored using Normalisation Process Theory (NPT) and the COM-B model. MAIN FINDINGS Risk-based stratified care (subgrouping and matching treatments) was found to have 'coherence' (i.e. made sense) to several clinicians and patients, in that it was well-integrated in practice, and supported clinical decision-making. However, for some GPs stratified care was less 'meaningful', as the risk-stratification tool did not fit with usual ways of consulting and added to already time-pressured consultations. GPs reported giving more patients written information/advice due to easier access to electronic information leaflets through the trial template and were motivated to refer patients to physiotherapy as they believed the trial resulted in faster physiotherapy access (although this was not the case). Patients and clinicians reported that risk-based stratified care influenced conversations in the consultation, prompting greater attention to psychosocial factors, and facilitating negotiation of treatment options. Physiotherapists saw benefits in receiving information about patients' risk subgroup on referral forms. CONCLUSION These findings provide context for interpreting some of the trial outcomes, particularly in relation to changes in clinical decision-making when risk-based stratified care was used. Findings also indicate potential reasons for lack of GP engagement with risk-based stratified care. Positive outcomes were identified that were not captured in the quantitative data, specifically that risk-based stratified care positively influenced some GP-patient conversations and facilitated negotiation of treatment options. TRIAL REGISTRATION ISRCTN15366334 (26/04/2016).
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Affiliation(s)
- Benjamin Saunders
- grid.9757.c0000 0004 0415 6205Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Adrian Chudyk
- grid.9757.c0000 0004 0415 6205Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Joanne Protheroe
- grid.9757.c0000 0004 0415 6205Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Vincent Cooper
- grid.9757.c0000 0004 0415 6205Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Bernadette Bartlam
- grid.9757.c0000 0004 0415 6205Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
| | - Hollie Birkinshaw
- grid.5491.90000 0004 1936 9297Faculty of Environmental and Life Sciences (FELS), University of Southampton, Southampton, UK
| | - Nadine E Foster
- grid.9757.c0000 0004 0415 6205Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK ,grid.1003.20000 0000 9320 7537STARS Research and Education Alliance, Surgical Treatment and Rehabilitation Service, The University of Queensland and Metro North Hospital and Health Service, QLD Herston, Australia
| | - Jonathan C Hill
- grid.9757.c0000 0004 0415 6205Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
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Karstens S, Zebisch J, Wey J, Hilfiker R, Hill JC. Validation of the German version of the STarT-MSK-Tool: A cohort study with patients from physiotherapy clinics. PLoS One 2022; 17:e0269694. [PMID: 35776764 PMCID: PMC9249194 DOI: 10.1371/journal.pone.0269694] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 05/25/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The STarT-MSK-Tool is an adaptation of the well established STarT-Back-Tool, used to risk-stratify patients with a wider range of musculoskeletal presentations. OBJECTIVE To formally translate and cross-culturally adapt the Keele STarT-MSK risk stratification tool into German (STarT-MSKG) and to establish its reliability and validity. METHODS A formal, multi-step, forward and backward translation approach was used. To assess validity patients aged ≥18 years, with acute, subacute or chronic musculoskeletal presentations in the lumbar spine, hip, knee, shoulder, or neck were included. The prospective cohort was used with initial data collected electronically at the point-of-consultation. Retest and 6-month follow-up questionnaires were sent by email. Test-retest reliability, construct validity, discriminative ability, predictive ability and floor or ceiling effects were analysed using intraclass correlation coefficient, and comparisons with a reference standard (Orebro-Musculoskeletal-Pain-Questionnaire: OMPQ) using correlations, ROC-curves and regression models. RESULTS The participants' (n = 287) mean age was 47 (SD = 15.8) years, 51% were female, with 48.8% at low, 43.6% at medium, and 7.7% at high risk. With ICC = 0.75 (95% CI 0.69; 0.81) test-retest-reliability was good. Construct validity was good with correlations for the STarT-MSKG-Tool against the OMPQ-Tool of rs = 0.74 (95% CI 0.68, 0.79). The ability of the tool [comparison OMPQ] to predict 6-month pain and disability was acceptable with AUC = 0.77 (95% CI 0.71, 0.83) [OMPQ = 0.74] and 0.76 (95% CI 0.69, 0.82) [OMPQ = 0.72] respectively. However, the explained variance (linear/logistic regression) for predicting 6-month pain (21% [OMPQ = 17%]/logistic = 29%) and disability (linear = 20%:[OMPQ = 19%]/logistic = 26%), whilst being comparable to the existing OMPQ reference standard, fell short of the a priori target of ≥30%. CONCLUSIONS The German version of the STarT-MSK-Tool is a valid instrument for use across multiple musculoskeletal conditions and is availabe for use in clinical practice. Comparison with the OMPQ suggests it is a good alternative.
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Affiliation(s)
- Sven Karstens
- Department of Computer Science, Therapeutic Sciences, Trier University of Applied Sciences, Trier, Germany
- * E-mail:
| | | | - Johannes Wey
- Department of Computer Science, Formerly Therapeutic Sciences, Trier University of Applied Sciences, Trier, Germany
| | - Roger Hilfiker
- School of Health Sciences, HES-SO Valais-Wallis, Leukerbad, Switzerland
| | - Jonathan C. Hill
- School of Medicine, Keele University, Staffordshire, United Kingdom
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Hill J, Try F, Agnew G, Saywell N. Perspectives and experiences of physiotherapists and general practitioners in the use of the STarT Back Tool: a review and meta-synthesis. J Prim Health Care 2022; 14:164-172. [PMID: 35771704 DOI: 10.1071/hc21069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 05/11/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction The STarT Back Tool (SBT) is used to triage people with acute low back pain (LBP) into treatment groups, matched to their risk of chronicity. It was developed in the UK where it has been shown to improve clinical outcomes, patient satisfaction, and reduce time off work. Successful implementation of the SBT outside the UK is dependent on health practitioner's attitudes and the healthcare system in which they work. Gaining health practitioners' perspectives on the SBT is an important step in implementation. Methods A computerised search of qualitative literature was conducted across seven databases in March 2021 using keywords to identify studies investigating the perspectives of physiotherapists and general practitioners on the use of the SBT in primary health care. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) tool. Data were coded and analysed using reflexive thematic analysis. Results Eight articles met inclusion criteria and included the views of 76 physiotherapists and 65 general practitioners, working in primary health care in four countries. Three themes were created from the data: 'Making it work', identifies factors that influence implementation and continued use of the SBT. The second 'will I do it?', captured potential consequences of adopting the SBT, and the third, 'it's all about the patient' emphasised how the SBT may affect patients. Discussion Physiotherapists and general practitioners found using the SBT frequently enhanced practice. General practitioners expressed concerns about time constraints and the SBT's potential to undermine clinical experience. Findings from this study will inform modifications to contextualise the tool to each healthcare environment.
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Affiliation(s)
- Julia Hill
- Department of Physiotherapy, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand; and Active Living and Rehabilitation: Aotearoa New Zealand, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Freya Try
- Department of Physiotherapy, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Georgia Agnew
- Department of Physiotherapy, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Nicola Saywell
- Department of Physiotherapy, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
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Gorgon E, Maka K, Kam A, Nisbet G, Sullivan J, Regan G, Pourkazemi F, Lin J, Mohamed M, Leaver A. Needs assessment for health service design for people with back pain in a hospital setting: A qualitative study. Health Expect 2022; 25:721-731. [PMID: 35150036 PMCID: PMC8957737 DOI: 10.1111/hex.13419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/05/2021] [Accepted: 12/14/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND There is a need for effective health service solutions to provide greater structure and support for implementing evidence-based practice in back pain care. Patient involvement in developing these solutions is crucial to increase relevance, acceptability and uptake. OBJECTIVES To determine patients' perceived needs and barriers to best-practice back pain care, and potential solutions to better address care needs. The study is the third in a series of needs assessment studies feeding into the 'idea generation' for service design in a large teaching hospital in a culturally and linguistically diverse community in metropolitan Sydney, Australia. DESIGN We conducted a combination of focus groups and in-depth interviews using an interpretive description approach. We used inductive thematic analysis to identify the main themes. SETTING AND PARTICIPANTS We purposively sampled patients with diverse characteristics from the neurosurgery and physiotherapy outpatient clinics, in particular those whose primary language was English, Arabic, Persian or Mandarin. Non-English audio recordings were translated and transcribed by bilingual researchers. RESULTS There were 24 participants (focus groups = 9; individual interviews = 15) when data saturation was reached. The analysis identified three key themes with several subthemes around what service designers needed to understand in helping people with back pain in this setting: (1) This is who I am; (2) It's not working for me; and (3) What I think I need. DISCUSSION AND CONCLUSION This study highlights that perceived unmet needs of patients are underpinned by unhelpful beliefs about the causes of and solutions for back pain, misaligned care expectations, unclear expectations of the hospital role and fragmentations in the health system. To design and implement a service that can deliver better back pain care, several solutions need to be integrated around: developing new resources that challenge unhelpful beliefs and set realistic expectations; improving access to education and self-management resources; focusing on individualized care; using a collaborative multidisciplinary approach within the hospital; and better connecting with and directing primary health care services. PATIENT OR PUBLIC CONTRIBUTION A consumer representative of the Western Sydney Local Health District provided input during study conceptualisation and is duly recognized in the Acknowledgements section.
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Affiliation(s)
- Edward Gorgon
- Sydney School of Health Sciences, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
- Department of Physical TherapyUniversity of the Philippines ManilaManilaPhilippines
| | - Katherine Maka
- Western Sydney Local Health DistrictNew South Wales HealthSydneyAustralia
| | - Andrew Kam
- Western Sydney Local Health DistrictNew South Wales HealthSydneyAustralia
| | - Gillian Nisbet
- Sydney School of Health Sciences, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Justin Sullivan
- Sydney School of Health Sciences, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Gerard Regan
- Western Sydney Local Health DistrictNew South Wales HealthSydneyAustralia
| | - Fereshteh Pourkazemi
- Sydney School of Health Sciences, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
| | - Jianhua Lin
- Sydney School of Health Sciences, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
- Department of Rehabilitation Therapy, Shanghai Yangzhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center)Tongji University School of MedicineShanghaiChina
| | - Mahmoud Mohamed
- Western Sydney Local Health DistrictNew South Wales HealthSydneyAustralia
| | - Andrew Leaver
- Sydney School of Health Sciences, Faculty of Medicine and HealthThe University of SydneySydneyAustralia
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Simpson P, Holopainen R, Schütze R, O'Sullivan P, Smith A, Linton SJ, Nicholas M, Kent P. Training of Physical Therapists to Deliver Individualized Biopsychosocial Interventions to Treat Musculoskeletal Pain Conditions: A Scoping Review. Phys Ther 2021; 101:6330890. [PMID: 34331758 DOI: 10.1093/ptj/pzab188] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 05/05/2021] [Accepted: 06/17/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Current guidelines recommend management of musculoskeletal pain conditions from a biopsychosocial approach; however, biopsychosocial interventions delivered by physical therapists vary considerably in effectiveness. It is unknown whether the differences are explained by the intervention itself, the training and/or competency of physical therapists delivering the intervention, or fidelity of the intervention. The aim was to investigate and map the training, competency assessments, and fidelity checking of individualized biopsychosocial interventions delivered by physical therapists to treat musculoskeletal pain conditions. METHODS A scoping review methodology was employed, using Arksey and O'Malley's framework. Seven electronic databases were searched between January and March 2019, with a bridge search completed in January 2020. Full-text peer-reviewed articles, with an individualized biopsychosocial intervention were considered, and 35 studies were included. RESULTS Reporting overall was sparse and highly variable. There was a broad spectrum of training. More sophisticated training involved workshops combining didactic and experiential learning over longer durations with supervision and feedback. Less sophisticated training was brief, involving lectures or seminars, with no supervision or feedback. Competency assessments and fidelity testing were underperformed. CONCLUSIONS Training in some interventions might not have facilitated the implementation of skills or techniques to enable the paradigm shift and behavior change required for physical therapists to effectively deliver a biopsychosocial intervention. Lack of competency assessments and fidelity checking could have impacted the methodological quality of biopsychosocial interventions. IMPACT This study highlighted problematic reporting, training, assessment of competency, and fidelity checking of physical therapist-delivered individualized biopsychosocial interventions. Findings here highlight why previous interventions could have shown small effect sizes and point to areas for improvement in future interventions. These findings can help inform future research and facilitate more widespread implementation of physical therapist-delivered biopsychosocial interventions for people with musculoskeletal pain and thereby improve their quality of life.
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Affiliation(s)
- Phoebe Simpson
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Riikka Holopainen
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Robert Schütze
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Peter O'Sullivan
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia.,Bodylogic Physiotherapy, Perth, Western Australia, Australia
| | - Anne Smith
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | - Steven J Linton
- Center for Health and Medical Psychology, Örebro University, Örebro, Sweden
| | - Michael Nicholas
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Peter Kent
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia.,Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
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Morsø L, Olsen Rose K, Schiøttz-Christensen B, Sowden G, Søndergaard J, Christiansen DH. Effectiveness of stratified treatment for back pain in Danish primary care: A randomized controlled trial. Eur J Pain 2021; 25:2020-2038. [PMID: 34101953 PMCID: PMC8518659 DOI: 10.1002/ejp.1818] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 05/30/2021] [Indexed: 11/08/2022]
Abstract
Background A randomized controlled trial (RCT) of stratified care demonstrated superior clinical outcomes and cost‐effectiveness for low back pain (LBP) patients in UK primary care. This is the first study in Europe, outside of the original UK study, to investigate the clinical efficacy and cost‐effectiveness of stratified care compared with current practice for patients with non‐specific LBP. Methods The study was a two‐armed RCT. Danish primary care patients with LBP were randomized to stratified care (n = 169) or current practice (n = 164). Primary outcomes at 3‐ and 12‐months' follow‐up were Roland Morris Disability Questionnaire (RDMQ), patient‐reported global change and time off work. Secondary outcomes included pain intensity, patient satisfaction, healthcare resource utilization and quality‐adjusted life years. Results Intention‐to‐treat analyses found no between‐group difference in RMDQ scores at 3 months (0.5, 95% CI −1.8 to 0.9) or 12 months (0.4, −2.1 to 1.3). No overall differences were found between the arms at 3 and 12 months with respect to time off work or secondary outcomes. Stratified care intervention resulted in significantly fewer treatment sessions (3.5 [SD 3.1] vs. 4.5 [3.5]) and significantly lower total healthcare costs (€) (13.4 [529] vs. 228 [830], p = .002). There was no difference in cost‐effectiveness (0.09, 0.05 to 0.13 vs. 0.10, 0.07–0.14, p = .70). Conclusions There was no significant difference in clinical outcomes between patients with non‐specific LBP receiving stratified care and those receiving current practice. However, stratified care may reduce total healthcare costs if implemented in Danish primary care. Significance Stratified care for low back pain based on risk profile is recommended by recent evidence based clinical guidelines. This study is the first broad replication of the STarT Back Trial in Europe. Therefore, the study adds to the body of knowledge evaluating the effectiveness of stratified care for low back pain in primary care, and provides insight into the effects of stratification on clinical practice.
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Affiliation(s)
- Lars Morsø
- Clinical Department, University of Southern Denmark, Odense, Denmark
| | - Kim Olsen Rose
- Department of Business and Economics, DaCHE, University of Southern Denmark, Odense, Denmark
| | | | | | - Jens Søndergaard
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - David H Christiansen
- Department of Occupational Medicine, Regional Hospital West Jutland, University Research Clinic, Herning, Denmark
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Delitto A, Patterson CG, Stevans JM, Freburger JK, Khoja SS, Schneider MJ, Greco CM, Freel JA, Sowa GA, Wasan AD, Brennan GP, Hunter SJ, Minick KI, Wegener ST, Ephraim PL, Beneciuk JM, George SZ, Saper RB. Stratified care to prevent chronic low back pain in high-risk patients: The TARGET trial. A multi-site pragmatic cluster randomized trial. EClinicalMedicine 2021; 34:100795. [PMID: 33870150 PMCID: PMC8040279 DOI: 10.1016/j.eclinm.2021.100795] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Many patients with acute low back pain (LBP) first seek care from primary care physicians. Evidence is lacking for interventions to prevent transition to chronic LBP in this setting. We aimed to test if implementation of a risk-stratified approach to care would result in lower rates of chronic LBP and improved self-reported disability. METHODS We conducted a pragmatic, cluster randomized trial using 77 primary care clinics in four health care systems across the United States. Practices were randomly assigned to a stratified approach to care (intervention) or usual care (control). Using the STarTBack screening tool, adults with acute LBP were screened low, medium, and high-risk. Patients screened as high-risk were eligible. The intervention included electronic best practice alerts triggering referrals for psychologically informed physical therapy (PIPT). PIPT education was targeted to community clinics geographically close to intervention primary care clinics. Primary outcomes were transition to chronic LBP and self-reported disability at six months. Trial Registry: ClinicalTrials.gov NCT02647658. FINDINGS Between May 2016 and June 2018, 1207 patients from 38 intervention and 1093 from 37 control practices were followed. In the intervention arm, around 50% of patients were referred for physical therapy (36% for PIPT) compared to 30% in the control. At 6 months, 47% of patients reported transition to chronic LBP in the intervention arm (38 practices, n = 658) versus 51% of patients in the control arm (35 practices, n = 635; OR=0.83 95% CI 0.64, 1.09; p = 0.18). No differences in disability were detected (difference -2·1, 95% CI -4.9-0.6; p = 0.12). Opioids and imaging were prescribed in 22%-25% and 23%-26% of initial visits, for intervention and control, respectively. Twelve-month LBP utilization was similar in the two groups. INTERPRETATION There were no differences detected in transition to chronic LBP among patients presenting with acute LBP using a stratified approach to care. Opioid and imaging prescribing rates were non-concordant with clinical guidelines. FUNDING Patient-Centered Outcomes Research Institute (PCORI) contract # PCS-1402-10867.
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Affiliation(s)
- Anthony Delitto
- School of Health and Rehabilitation Sciences, University of Pittsburgh, 4029 Forbes Tower, Pittsburgh, PA 15260 USA
- Corresponding author.
| | - Charity G. Patterson
- School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA
| | - Joel M. Stevans
- School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA
| | - Janet K. Freburger
- School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA
| | - Samannaaz S. Khoja
- School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA
| | - Michael J. Schneider
- School of Health and Rehabilitation Sciences, University of Pittsburgh, 100 Technology Drive, Pittsburgh, PA 15219 USA
| | - Carol M. Greco
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Jennifer A. Freel
- Physician Network and Quality, St. Clair Hospital, 1000 Bower Hill Road, Pittsburgh, PA 15243 USA
| | - Gwendolyn A. Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 Fifth Avenue, Suite 1103, Pittsburgh, PA 15213, USA
| | - Ajay D. Wasan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | - Gerard P. Brennan
- 5848 South 300 East, Intermountain Healthcare Rehabilitation Services, Murray, Utah, 84107 USA
| | - Stephen J. Hunter
- 5848 South 300 East, Intermountain Healthcare Rehabilitation Services, Murray, Utah, 84107 USA
| | - Kate I. Minick
- 5848 South 300 East, Intermountain Healthcare Rehabilitation Services, Murray, Utah, 84107 USA
| | - Stephen T. Wegener
- 600 N. Wolfe Street, Johns Hopkins University School of Medicine, Baltimore, Maryland, 21287 USA
| | - Patti L. Ephraim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E Monument Street, Baltimore, MD 21287, USA
| | - Jason M. Beneciuk
- Department of Physical Therapy, Box 100154, University of Florida College of Public Health and Health Professions, Gainesville, Florida, 32610 USA
| | - Steven Z. George
- Duke Clinical Research Institute and Department of Orthopaedic Surgery, 200 Morris Street, Duke University, Durham, North Carolina, 27701 USA
| | - Robert B. Saper
- Department of Family Medicine, Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118 USA
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Karstens S, Lang S, Saunders B. Patients' Views on the Implementation Potential of a Stratified Treatment Approach for Low Back Pain in Germany: A Qualitative Study. Health Serv Insights 2020; 13:1178632920977894. [PMID: 33343197 PMCID: PMC7727085 DOI: 10.1177/1178632920977894] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/10/2020] [Indexed: 12/30/2022] Open
Abstract
Stratified care for low back pain (LBP) has been shown to be clinically- and cost-effective in the UK, but its transferability to the German healthcare system is unknown. This study explores LBP patients’ perspectives regarding future implementation of stratified care, through in-depth interviews (n = 12). The STarT-Back-Tool was completed by participants prior to interviews. Interview data were analysed using Grounded Theory. The overarching theme identified from the data was ‘treatment-success’, with subthemes of ‘assessment and treatment planning’, ‘acceptance of the questionnaire’ and ‘contextual factors’. Patients identified the underlying cause of pain as being of great importance (whereas STarT-Back allocates treatment based on prognosis). The integration of the STarT-Back-Tool in consultations was considered helpful as long as it does not disrupt the therapeutic relationship, and was acceptable if tool results are handled confidentially. Results indicate that for patients to find STarT-Back acceptable, the shift from a focus on identifying a cause of pain and subsequent diagnosis, to prediction-orientated treatment planning, must be made clear. Patient ‘buy in’ is important for successful uptake of clinical interventions, and findings can help to inform future strategies for implementing STarT-Back in the Germany, as well as having potential implications for transferability to other similar healthcare systems.
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Affiliation(s)
- Sven Karstens
- Department of Computer Science; Therapeutic Sciences, Trier University of Applied Sciences, Trier, Germany
| | - Sarah Lang
- MSc Sport Physiotherapy, German Sport University Cologne, Cologne, Germany
| | - Benjamin Saunders
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK
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Middleton A, Fitzgerald GK, Delitto A, Saper RB, Gergen Barnett K, Stevans J. Implementing stratified care for acute low back pain in primary care using the STarT Back instrument: a process evaluation within the context of a large pragmatic cluster randomized trial. BMC Musculoskelet Disord 2020; 21:776. [PMID: 33238964 PMCID: PMC7689997 DOI: 10.1186/s12891-020-03800-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/17/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although risk-stratifying patients with acute lower back pain is a promising approach for improving long-term outcomes, efforts to implement stratified care in the US healthcare system have had limited success. The objectives of this process evaluation were to 1) examine variation in two essential processes, risk stratification of patients with low back pain and referral of high-risk patients to psychologically informed physical therapy and 2) identify barriers and facilitators related to the risk stratification and referral processes. METHODS We used a sequential mixed methods study design to evaluate implementation of stratified care at 33 primary care clinics (17 intervention, 16 control) participating in a larger pragmatic trial. We used electronic health record data to calculate: 1) clinic-level risk stratification rates (proportion of patients with back pain seen in the clinic over the study period who completed risk stratification questionnaires), 2) rates of risk stratification across different points in the clinical workflow (front desk, rooming, and time with clinician), and 3) rates of referral of high-risk patients to psychologically informed physical therapy among intervention clinics. We purposively sampled 13 clinics for onsite observations, which occurred in month 24 of the 26-month study. RESULTS The overall risk stratification rate across the 33 clinics was 37.8% (range: 14.7-64.7%). Rates were highest when patients were identified as having back pain by front desk staff (overall: 91.9%, range: 80.6-100%). Rates decreased as the patient moved further into the visit (rooming, 29.3% [range: 0-83.3%]; and time with clinician, 11.3% [range: 0-49.3%]. The overall rate of referrals of high-risk patients to psychologically informed physical therapy across the 17 intervention clinics was 42.1% (range: 8.3-70.8%). Barriers included staffs' knowledge and beliefs about the intervention, patients' needs, technology issues, lack of physician engagement, and lack of time. Adaptability of the processes was a facilitator. CONCLUSIONS Adherence to key stratified care processes varied across primary care clinics and across points in the workflow. The observed variation suggests room for improvement. Future research is needed to build on this work and more rigorously test strategies for implementing stratified care for patients with low back pain in the US healthcare system. TRIAL REGISTRATION Trial registration: ClinicalTrials.gov ( NCT02647658 ). Registered January 6, 2016.
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Affiliation(s)
- Addie Middleton
- New England Geriatric Research Education and Clinical Center, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130-4817, USA.
| | - G Kelley Fitzgerald
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anthony Delitto
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert B Saper
- Department of Family Medicine, Boston Medical Center, Boston, MA, USA
| | | | - Joel Stevans
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
- Health Policy Institute, University of Pittsburgh, Pittsburgh, PA, USA
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21
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Saunders B, Hill JC, Foster NE, Cooper V, Protheroe J, Chudyk A, Chew-Graham C, Bartlam B. Stratified primary care versus non-stratified care for musculoskeletal pain: qualitative findings from the STarT MSK feasibility and pilot cluster randomized controlled trial. BMC FAMILY PRACTICE 2020; 21:31. [PMID: 32046656 PMCID: PMC7014618 DOI: 10.1186/s12875-020-1098-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/27/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Stratified care involves subgrouping patients based on key characteristics, e.g. prognostic risk, and matching these subgroups to appropriate early treatment options. The STarT MSK feasibility and pilot cluster randomised controlled trial (RCT) examined the feasibility of a future main trial and of delivering prognostic stratified primary care for patients with musculoskeletal pain. The pilot RCT was conducted in 8 UK general practices (4 stratified care; 4 usual care) with 524 patients. GPs in stratified care practices were asked to use i) the Keele STarT MSK development tool for risk-stratification and ii) matched treatment options for patients at low-, medium- and high-risk of persistent pain. This paper reports on a nested qualitative study exploring the feasibility of delivering stratified care ahead of the main trial. METHODS 'Stimulated-recall' interviews were conducted with patients and GPs in the stratified care arm (n = 10 patients; 10 GPs), prompted by consultation recordings. Data were analysed thematically and mapped onto the COM-B behaviour change model; exploring the Capability, Opportunity and Motivation GPs and patients had to engage with stratified care. RESULTS Patients reported positive views that stratified care enabled a more 'structured' consultation, and felt tool items were useful in making GPs aware of patients' worries and concerns. However, the closed nature of the tool's items was seen as a barrier to opening up discussion. GPs identified difficulties integrating the tool within consultations (Opportunity), but found this easier as it became more familiar. Whilst both groups felt the tool had added value, they identified 'cumbersome' items which made it more difficult to use (Capability). Most GPs reported that the matched treatment options aided their clinical decision-making (Motivation), but identified some options that were not available to them (e.g. pain management clinics), and other options that were not included in the matched treatments but which were felt appropriate for some patients (e.g. consider imaging). CONCLUSION This nested qualitative study, using the COM-B model, identified amendments required for the main trial including changes to the Keele STarT MSK tool and matched treatment options, targeting the COM-B model constructs, and these have been implemented in the current main trial. TRIAL REGISTRATION ISRCTN 15366334.
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Affiliation(s)
- Benjamin Saunders
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK.
| | - Jonathan C Hill
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Nadine E Foster
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
- Keele Clinical Trials Unit (CTU), School for Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Vince Cooper
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Joanne Protheroe
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Adrian Chudyk
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Carolyn Chew-Graham
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Bernadette Bartlam
- Primary Care Centre Versus Arthritis, School for Primary, Community and Social Care, Keele University, Keele, Staffordshire, ST5 5BG, UK
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 308232, Singapore
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22
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Delitto A, Patterson CG, Stevans JM, Brennan GP, Wegener ST, Morrisette DC, Beneciuk JM, Freel JA, Minick KI, Hunter SJ, Ephraim PL, Friedman M, Simpson KN, George SZ, Daley KN, Albert MC, Tamasy M, Cash J, Lake DS, Freburger JK, Greco CM, Hough LJ, Jeong JH, Khoja SS, Schneider MJ, Sowa GA, Spigle WA, Wasan AD, Adams WG, Lemaster CM, Mishuris RG, Plumb DL, Williams CT, Saper RB. Study protocol for targeted interventions to prevent chronic low back pain in high-risk patients: A multi-site pragmatic cluster randomized controlled trial (TARGET Trial). Contemp Clin Trials 2019; 82:66-76. [PMID: 31136834 DOI: 10.1016/j.cct.2019.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/16/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Low back pain (LBP) is one of the most prevalent and potentially disabling conditions for which people seek health care. Patients, providers, and payers agree that greater effort is needed to prevent acute LBP from transitioning to chronic LBP. METHODS AND STUDY DESIGN The TARGET (Targeted Interventions to Prevent Chronic Low Back Pain in High-Risk Patients) Trial is a primary care-based, multisite, cluster randomized, pragmatic trial comparing guideline-based care (GBC) to GBC + referral to Psychologically Informed Physical Therapy (PIPT) for patients presenting with acute LBP and identified as high risk for persistent disabling symptoms. Study sites include primary care clinics within each of five geographical regions in the United States, with clinics randomized to either GBC or GBC + PIPT. Acute LBP patients at all clinics are risk stratified (high, medium, low) using the STarT Back Tool. The primary outcomes are the presence of chronic LBP and LBP-related functional disability determined by the Oswestry Disability Index at 6 months. Secondary outcomes are LBP-related processes of health care and utilization of services over 12 months, determined through electronic medical records. Study enrollment began in May 2016 and concluded in June 2018. The trial was powered to include at least 1860 high-risk patients in the randomized controlled trial cohort. A prospective observational cohort of approximately 6900 low and medium-risk acute LBP patients was enrolled concurrently. DISCUSSION The TARGET pragmatic trial aims to establish the effectiveness of the stratified approach to acute LBP intervention targeting high-risk patients with GBC and PIPT. TRIAL REGISTRATION ClinicalTrials.govNCT02647658 Registered Jan. 6, 2016.
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Affiliation(s)
- Anthony Delitto
- School of Health and Rehabilitation Sciences (SHRS), University of Pittsburgh, 4028 Forbes Tower, Pittsburgh, PA 15260, USA.
| | - Charity G Patterson
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Joel M Stevans
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Gerard P Brennan
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Stephen T Wegener
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - David C Morrisette
- Division of Physical Therapy, College of Health Professions, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Jason M Beneciuk
- Department of Physical Therapy, College of Public Health & Health Professions, University of Florida, Box 100154, UFHSC, Gainesville, FL 32610, USA
| | - Jennifer A Freel
- Wolff Center at UPMC, 4601 Baum Blvd, Suite 228, Pittsburgh, PA 15213, USA
| | - Kate I Minick
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Stephen J Hunter
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Patti L Ephraim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E Monument Street, Baltimore, MD 21287, USA
| | - Michael Friedman
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Steven Z George
- Duke Clinical Research Institute and Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27705, USA
| | - Kelly N Daley
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Michael C Albert
- Johns Hopkins Community Physicians, 6225 Smith Avenue, Baltimore, MD 21209, USA
| | - Marie Tamasy
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Jewel Cash
- Boston Medical Center, Boston, MA 02118, USA
| | - D Scott Lake
- Intermountain Healthcare, The Orthopaedic Specialty Hospital, 5848 South 300 East, Murray, UT 84107, USA
| | - Janet K Freburger
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Carol M Greco
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
| | - Linda J Hough
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Jong-Hyeon Jeong
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, 130 De Soto Street, Pittsburgh, PA 15261, USA
| | - Samannaaz S Khoja
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Michael J Schneider
- Department of Physical Therapy, SHRS, University of Pittsburgh, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA
| | - Gwendolyn A Sowa
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, 3471 Fifth Avenue, Suite 1103, Pittsburgh, PA 15213, USA
| | - Wendy A Spigle
- Wolff Center at UPMC, 4601 Baum Blvd, Suite 228, Pittsburgh, PA 15213, USA
| | - Ajay D Wasan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | - William G Adams
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Chelsey M Lemaster
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Rebecca G Mishuris
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Dorothy L Plumb
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Charles T Williams
- Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
| | - Robert B Saper
- Department of Family Medicine, Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA
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