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Lafrance S, Santaguida C, Perreault K, Bath B, Hébert LJ, Feldman D, Thavorn K, Fernandes J, Desmeules F. Is One Enough? The Effectiveness of a Single Session of Education and Exercise Compared to Multiple Sessions of a Multimodal Physiotherapy Intervention for Adults With Spinal Disorders in an Advanced Practice Physiotherapy Model of Care: A Randomized Controlled Trial. J Orthop Sports Phys Ther 2024; 54:1-13. [PMID: 39348218 DOI: 10.2519/jospt.2024.12618] [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] [Indexed: 10/02/2024]
Abstract
OBJECTIVE: To assess the effectiveness of a single session of education and exercise compared with multiple sessions of a multimodal physiotherapy intervention for adults with spinal disorders in an advanced practice physiotherapy specialized spine model of care. DESIGN: Pragmatic randomized controlled trial. METHODS: We randomized patients with spinal disorders, who were referred for a spinal surgery consultation and triaged as nonsurgical cases by an advanced practice physiotherapist, to a single session of education and prescription of an exercise program (n = 52) or multiple sessions (6 in total) of a multimodal physiotherapy intervention (n = 54). The primary outcomes were the short form Brief Pain Inventory pain severity scale (BPI-S) and the Brief Pain Inventory pain interference scale (BPI-I), and secondary outcomes included disability, quality of life, catastrophization, and satisfaction. Linear mixed models were used to assess differences between groups across time points at 6, 12, and 26 weeks. RESULTS: There were no significant between-group differences on the BPI-S and only a significant improvement at 6 weeks on the BPI-I in the multiple-session group (mean difference: -0.96/10; 95% CI, -1.87 to -0.05). There were no other statistically significant differences between groups, except for satisfaction where participants in the multiple-session group reported statistically significantly greater satisfaction on the 9-item Visit-Specific Satisfaction Questionnaire and the MedRisk questionnaire. Both groups saw significant improvements over time on all outcomes except for the BPI-S. CONCLUSION: Adding supervised multimodal physiotherapy sessions did not result in better clinical outcomes when compared to a single session of education and exercise. Patients were more satisfied with the multiple-session approach. J Orthop Sports Phys Ther 2024;54(10):1-13. Epub 9 September 2024. doi:10.2519/jospt.2024.12618.
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Han CS, Hancock MJ, Jones CMP, Maher CG. Evaluating the STarTBack stratified treatment approach for low back pain: exploring study-level factors potentially explaining differences in results of studies - a literature review. BMJ Open 2024; 14:e081704. [PMID: 38925707 PMCID: PMC11202665 DOI: 10.1136/bmjopen-2023-081704] [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: 11/03/2023] [Accepted: 05/31/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVE To explore if there are differences in the design and/or conduct of studies that have tested the STarTBack treatment approach for the management of low back pain (LBP), potentially explaining differences in study results. DESIGN A literature review. DATA SOURCES MEDLINE, CINAHL and EMBASE were searched from inception to 26 July 2023. ELIGIBILITY CRITERIA We included studies that included (1) participants with LBP and/or leg pain, (2) randomised controlled trials, controlled clinical trials and interrupted time series designs, (3) used the STarTBack Tool to stratify participants into subgroups and (4) studies provided matched treatments according to participants STarTBack score. DATA EXTRACTION AND SYNTHESIS Two review authors independently reviewed the search results and extracted data into the data extraction form. Due to the exploratory nature of this study, results are presented descriptively. RESULTS 11 studies conducted across 5 countries were included. There were substantial differences in the proportion of participants allocated to the different risk groups; low-risk group (range: 19%-58%), medium risk group (range: 31%-52%) and high-risk group (range: 6%-38%). There were large differences between studies in the implementation of the STarTBack approach. The original STarTBack trial (Hill et al, 2011) had a more explanatory design while in many subsequent studies, the design was more pragmatic/real world. Only the two original studies provided clear evidence that the implementation of the STarTBack tool led to a higher proportion of participants receiving matched treatment. In the other studies, there was no evidence of a difference, or it was unclear. In two studies, a researcher made the decision about which matched treatment participants received based on the STartTback Tool, while in nine studies, this was done by a clinician. Most studies recommended the same matched treatment for each risk group as per the original study except for a small number of studies. Only three studies reported whether the clinician delivering matched treatment followed the recommended treatment as per the tool. There was substantial variability in the training clinicians received. CONCLUSIONS Reporting of important study-level factors (eg, differences in study design, whether clinicians were trained and how the tool was used in each study) in how the STarTBack approach was implemented was unclear. There is some suggestion that key factors may include the individual who implemented the STarTBack tool, whether the recommendations of the tool were followed, the amount of training the clinician delivering the matched treatment received, and whether clinicians actually delivered the matched treatment.
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Affiliation(s)
- Christopher S Han
- Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark J Hancock
- Macquarie University, North Epping, New South Wales, Australia
| | - Caitlin M P Jones
- Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christopher G Maher
- Institute for Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
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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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Furness J, Phillips J, Canetti E, Kemp-Smith K. Exploring mental health approaches and curriculum in physiotherapy: an Australasian perspective. Physiother Theory Pract 2024:1-15. [PMID: 38368604 DOI: 10.1080/09593985.2024.2316308] [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: 08/23/2023] [Accepted: 01/08/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Exposure to mental health problems are becoming increasingly more frequent within physiotherapy. Physiotherapists recognize the need for a biopsychosocial approach, however their knowledge, assessment, and treatment skills specific to mental health problems requires further research. PURPOSE To profile the level of education and perception of education that physiotherapists have acquired specific to mental health problems; and to profile an understanding of the current practice of physiotherapists specific to mental health problems. METHODS An online survey addressed the aims of the study and collected data from physiotherapists in Australia and New Zealand (open between 20th of October 2022 to the 20th of March 2023). RESULTS 139 respondents were included in the analysis. Physiotherapists had a perception that a significantly greater amount of coursework related to mental health needed to be included within their initial degree compared to what they received (mean difference of 20.0%, 95% CI: 17.5 to 22.5). This trend was evident irrespective of the degree level or the year of graduation. Higher perceived knowledge of anxiety (MD of 11.4, p = 0.001, ES: 0.5) and depression (MD of 11.8, p = 0.001, ES: 0.5) was evident in outpatient care physiotherapists. Lack of perceived knowledge is a reason for whether an assessment or treatment strategy is used with patients experiencing a mental health problem. Motivational interviewing and mindfulness were the most frequently used psychologically based techniques. CONCLUSION This study reveals the need to increase the amount of mental health and psychologically based techniques within Physiotherapy curriculum.
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Affiliation(s)
- J Furness
- Faculty of Health Science and Medicine. Bond Institute of Health and Sport Bond University, Robina, Gold Coast, Queensland, Australia
| | - J Phillips
- Faculty of Health Science and Medicine. Bond Institute of Health and Sport Bond University, Robina, Gold Coast, Queensland, Australia
- The Wesley Hospital, Uniting Care Health, Auchenflower, Brisbane, Queensland, Australia
| | - E Canetti
- Faculty of Health Science and Medicine. Bond Institute of Health and Sport Bond University, Robina, Gold Coast, Queensland, Australia
| | - K Kemp-Smith
- Faculty of Health Science and Medicine. Bond Institute of Health and Sport Bond University, Robina, Gold Coast, Queensland, Australia
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Johansen SK, Maclachlan L, Hillier R, Taylor G, Mellor R, Rathleff MS, Vicenzino B. Exploring patients' and physiotherapists' visions on modelling treatments and optimising self-management strategies for patellofemoral pain: A future workshop approach. Musculoskelet Sci Pract 2022; 60:102567. [PMID: 35468529 DOI: 10.1016/j.msksp.2022.102567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 03/24/2022] [Accepted: 04/14/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify challenges confronting patients and physiotherapists in managing patellofemoral pain by seeking their perspectives via generative activities involving critique, ideation and formulating shared visions for future treatments. DESIGN Two Future Workshops, Reflexive Thematic Analysis. METHODS We recruited 8 patients (median age 36 yrs, 4 women) who were experiencing patellofemoral pain and 10 physiotherapists (54 yrs, 8 women) who treated patients with the condition. Several vignette cases and design cards were constructed and included as tools for facilitating dialogue, throughout all three phases (each ∼40 min duration) of the workshops (i.e., critique, fantasy, implementation). Participants' discussions were audio recorded, transcribed and thematically analyzed independently by four investigators until no additional themes emerged. RESULTS/FINDINGS Four themes were identified; (i) challenges confronting patients, (ii) learning to manage patellofemoral pain (knowledge), (iii) stakeholder accountability and (iv) development/use of portable applications (apps). Some challenges and strategies were related to family and social networks, financial costs, and psychological factors. Knowledge related to the condition, mental and physical impact of pain, exercises and physical activity. The physiotherapist's role in moderating accurate information was raised, as was that of the GP and personal trainer. Visions of future treatments centered about the inclusion of flexible modes of communication and cultivating mutual accountability. Social determinants and the invisible work of patients in managing their condition was apparent. CONCLUSION Enacting patient centered care was sought/recommended - requiring consideration of social contexts and flexible delivery. The physiotherapist was seen as a source of accurate information and a point of accountability.
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Affiliation(s)
| | - Liam Maclachlan
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane & Women's Hospital, Brisbane, Australia; School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Ramie Hillier
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Glenn Taylor
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Rebecca Mellor
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia; Healthy Veteran Research Program, Gallipoli Medical Research Foundation, Brisbane, Australia
| | | | - Bill Vicenzino
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.
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Bourke MJ, Ferguson D, Cooke M. Patient Experiences of Self-Management for Chronic Low Back Pain: A Qualitative Study. Phys Ther 2022; 102:6556165. [PMID: 35358311 DOI: 10.1093/ptj/pzac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 11/08/2021] [Accepted: 02/02/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Chronic low back pain (CLBP) is a lifelong condition causing disability and distress. One aim of treatment is to enhance self-management. To date, self-management interventions have had limited effectiveness. A greater understanding of self-management for CLBP has the potential to improve future interventional trials. The purpose of this study was to identify the experience of CLBP self-management for patients attending outpatient physical therapy and assess how the experience of CLBP self-management changes over time. METHODS This qualitative study used constructivist grounded theory. Patients with CLBP who were attending an outpatient physical therapy department were recruited using convenience sampling. Each participant attended a semistructured interview. These were audio recorded and transcribed verbatim. The data were coded and thematically analyzed by the lead researcher. Recruitment continued until data saturation. Participants reviewed preliminary themes for validation. RESULTS Six subthemes emerged from 9 interviews: (1) self-doubt, (2) coping day to day, (3) independent discovery, (4) developing resilience, (5) health care: opportunity and threat, and (6) living with pain differently. Two themes took on greatest significance. Self-doubt appeared most strongly and was prevalent in all experiences. However, living with pain differently appeared in those who had developed a level of pain acceptance. These themes formed a conceptual model, "Fluctuating Uncertainty." CONCLUSION The experience of CLBP self-management is one of fluctuating self-doubt. Self-doubt is the predominant experience and is characterized by the perception of pain as a threat and low pain self-efficacy. During times of greater clarity, individuals develop strategies that increase pain self-efficacy and reinforce the perception of pain without threat. These are features of learning to live well with pain. IMPACT CLBP is a lifelong condition requiring self-management. The current study characterizes the self-management strategies used by patients attending physical therapy. The fluctuating nature of these strategies is dependent upon perception of pain and pain self-efficacy. LAY SUMMARY People with CLBP who self-manage their pain fluctuate between attempting to control pain and learning to live with pain. People who understand their condition develop wider-ranging self-management strategies.
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Affiliation(s)
- Maurice John Bourke
- Department of Physiotherapy, Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Diarmaid Ferguson
- Department of Physiotherapy, Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mary Cooke
- School of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
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Proposing six criteria to improve reproducibility of “usual care” interventions in back pain trials: a systematic review. J Clin Epidemiol 2022; 149:227-235. [DOI: 10.1016/j.jclinepi.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 04/25/2022] [Accepted: 05/07/2022] [Indexed: 11/22/2022]
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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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Perruccio AV, Wong JT, Badley EM, Power JD, Yip C, Rampersaud YR. Predictors of response following standardized education and self-management recommendations for low back pain stratified by dominant pain location. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 8:100092. [PMID: 35141656 PMCID: PMC8820018 DOI: 10.1016/j.xnsj.2021.100092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Anthony V. Perruccio
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network; Toronto, ON, Canada
- Arthritis Community Research and Evaluation Unit, University Health Network; Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto; Toronto, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Toronto; Toronto, ON, Canada
- Corresponding author at: Krembil Research Institute, 399 Bathurst St. - MP10-302, Toronto, ON M5T 2S8, Canada
| | - Jessica T.Y. Wong
- Dalla Lana School of Public Health, University of Toronto; Toronto, ON, Canada
| | - Elizabeth M. Badley
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network; Toronto, ON, Canada
- Arthritis Community Research and Evaluation Unit, University Health Network; Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto; Toronto, ON, Canada
| | - J. Denise Power
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network; Toronto, ON, Canada
| | - Calvin Yip
- Dalla Lana School of Public Health, University of Toronto; Toronto, ON, Canada
| | - Y. Raja Rampersaud
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network; Toronto, ON, Canada
- Department of Surgery, Faculty of Medicine, University of Toronto; Toronto, ON, Canada
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Wassinger CA, Sole G. Agreement and screening accuracy between physical therapists ratings and the Ӧrebro Musculoskeletal Pain Questionnaire in screening for risk of chronic pain during Musculoskeletal evaluation. Physiother Theory Pract 2021; 38:2949-2955. [PMID: 34266347 DOI: 10.1080/09593985.2021.1949766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Identifying patients at risk for chronic musculoskeletal pain can inform evaluation and treatment decisions. The ability of physical therapists to assess patients' risk for chronic pain without use of validated tools has been questioned. The Ӧrebro Musculoskeletal Pain Questionnaire (OMPQ) is used to determine risk for chronic pain.Methods: The aim of this pragmatic study was to prospectively quantify the agreement between physical therapists' assessment of patients' risk for chronic symptoms compared to the OMPQ. Patients were asked to complete the OMPQ during the initial visit. Physical therapists, blinded to OMPQ risk classification, carried out their usual patient assessment procedures. The physical therapists rated patients as either high or low risk for chronic pain based on their clinical assessment. Agreement between therapist and OMPQ was determined using Cohen's Kappa (κ) and screening accuracy compared clinician risk to the OMPQ risk classification (reference standard) by way of contingency table analysis.Results: Ninety-six (96) patients' risk classifications and 15 corresponding physical therapists' risk estimates were available for analysis. The OMPQ identified a 47% prevalence for high risk of chronic pain. Agreement (κ and 95% confidence interval) between physical therapist rating and OMPQ was slight, κ = 0.272 (0.033-0.421), p = .026. Therapists' sensitivity and specificity (95% CI) for determining risk classifications were 60.0% (44.3-74.3) and 62.8% (48.1-75.6), respectively. The positive and negative likelihood ratios (95% CI) were 1.61 (1.05-2.47) and 0.64 (0.42-0.97).Discussion: The use of validated self-report questionnaires are recommended to supplement clinician prognosis for patients at risk of chronic musculoskeletal pain.
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Affiliation(s)
- Craig A Wassinger
- Department of Physical Therapy, East Tennessee State University, Johnson City, USA
| | - Gisela Sole
- School of Physiotherapy, Centre for Health, Activity, and Rehabilitation Research, University of Otago, Dunedin, New Zealand
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Abdelnaeem AO, Rehan Youssef A, Mahmoud NF, Fayaz NA, Vining R. Psychometric properties of chronic low back pain diagnostic classification systems: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:957-989. [PMID: 33471180 DOI: 10.1007/s00586-020-06712-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 11/23/2020] [Accepted: 12/27/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To identify and critically appraise studies evaluating psychometric properties of functionally oriented diagnostic classification systems for Non-Specific Chronic Low Back Pain (NS-CLBP). METHODS This review employed methodology consistent with PRISMA guidelines. Electronic databases and journals: (PubMed, EMBASE, Cochrane, PEDro, CINAHL, Index to chiropractic literature, ProQuest, Physical Therapy, Journal of Physiotherapy, Canadian Physiotherapy and Physiotherapy Theory and Practice) were searched from inception until January 2020. Included studies evaluated the validity and reliability of NS-CLBP diagnostic classification systems in adults. Risk of bias was assessed using a Critical Appraisal Tool. RESULTS Twenty-two studies were eligible: Five investigated inter-rater reliability, and 17 studies analyzed validity of O'Sullivan's classification system (OCS, n = 15), motor control impairment (MCI) test battery (n = 1), and Pain Behavior Assessment (PBA, n = 1). Evidence from multiple low risk of bias studies demonstrates that OCS has moderate to excellent inter-rater reliability (kappa > 0.4). Also, two low risk of bias studies support of OCS-MCI subcategory. Three tests within the MCI test battery show acceptable inter- and intra-rater reliability for clinical use (the "sitting knee extension," the "one leg stance," and the "pelvic tilt" tests). Evidence for the reliability and validity of the PBA is limited to one high bias risk study. CONCLUSIONS Multiple low risk of bias studies demonstrate strong inter-rater reliability for OCS classification specifically OCS-MCI subcategory. Future studies with low risk of bias are needed to evaluate reliability and validity of the MCI test battery and the PBA.
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Affiliation(s)
| | - Aliaa Rehan Youssef
- Faculty of Physical Therapy, Cairo University, Cairo, Egypt.,Faculty of Physical Therapy, Ahram Canadian University, Giza, Egypt
| | | | | | - Robert Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, IA, 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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Kneeman J, Battalio SL, Korpak A, Cherkin DC, Luo G, Rundell SD, Suri P. Predicting Persistent Disabling Low Back Pain in Veterans Affairs Primary Care Using the STarT Back Tool. PM R 2020; 13:241-249. [PMID: 32902134 DOI: 10.1002/pmrj.12488] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 07/16/2020] [Accepted: 07/23/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The Subgrouping for Targeted Treatment (STarT Back) is a stratified care approach to low back pain (LBP) treatment. The predictive validity of STarT Back in Veterans Affairs (VA) primary care has not been demonstrated. OBJECTIVE To examine the validity of the STarT Back tool for predicting future persistent disabling LBP in VA primary care. DESIGN Cohort study. SETTING VA primary care in Washington State. PARTICIPANTS Veterans seeking care for LBP in VA primary care clinics. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The STarT Back tool was used to classify Veterans according to their baseline risk group (low vs medium vs high). The primary study outcome, persistent disabling LBP, was defined as a Roland-Morris Disability Questionnaire (RMDQ) score ≥ 7 at 6-month follow-up. Analyses examined discrimination and calibration of the baseline STarT Back risk groups for prediction of persistent disabling LBP at 6-month follow-up. RESULTS Of the study sample, 9% were female and 80% reported longstanding LBP (>5 year duration). Among 538 participants, the baseline STarT Back risk groups were associated with future persistent disabling LBP at 6-month follow-up. Within each baseline STarT Back risk group, the proportions with future persistent disabling LBP at 6-month follow-up were 54% (low risk), 88% (medium risk), and 97% (high risk). The baseline STarT Back risk groups had useful discrimination (area under the curve [AUC] 0.79) for predicting future persistent disabling LBP, but the proportion of Veterans with persistent disabling LBP at 6-month follow-up was substantially higher than that observed in non-VA primary care settings. CONCLUSIONS The STarT Back risk groups had useful discrimination (AUC = 0.79) for future persistent disabling LBP, but calibration was poor, underestimating the risk of persistent disabling LBP. The STarT Back tool may require updating for use in VA primary care.
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Affiliation(s)
- Jacob Kneeman
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | | | - Anna Korpak
- Seattle Epidemiologic Research and Information Center (ERIC, VA Puget Sound Health Care System, Seattle, WA
| | | | - Gang Luo
- Department of Biomedical Informatics and Education, University of Washington, Seattle, WA.,Clinical Learning, Evidence, and Research Center (CLEAR), University of Washington, Seattle, WA
| | - Sean D Rundell
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Pradeep Suri
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA.,Seattle Epidemiologic Research and Information Center (ERIC, VA Puget Sound Health Care System, Seattle, WA.,Clinical Learning, Evidence, and Research Center (CLEAR), University of Washington, Seattle, WA.,Division of Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, WA
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Risk-stratified and stepped models of care for back pain and osteoarthritis: are we heading towards a common model? Pain Rep 2020; 5:e843. [PMID: 33235943 PMCID: PMC7678800 DOI: 10.1097/pr9.0000000000000843] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 06/03/2020] [Accepted: 07/02/2020] [Indexed: 02/07/2023] Open
Abstract
Supplemental Digital Content is Available in the Text. Substantial overlap between interventions and models of care for osteoarthritis and low back pain suggests potential for one common model, which may facilitate implementation. The overall quality of care for musculoskeletal pain conditions is suboptimal, partly due to a considerable evidence-practice gap. In osteoarthritis and low back pain, structured models of care exist to help overcome that challenge. In osteoarthritis, focus is on stepped care models, where treatment decisions are guided by response to treatment, and increasingly comprehensive interventions are only offered to people with inadequate response to more simple care. In low back pain, the most widely known approach is based on risk stratification, where patients with higher predicted risk of poor outcome are offered more comprehensive care. For both conditions, the recommended interventions and models of care share many commonalities and there is no evidence that one model of care is more effective than the other. Limitations of existing models of care include a lack of integrated information on social factors, comorbid conditions, and previous treatment experience, and they do not support an interplay between health care, self-management, and community-based activities. Moving forwards, a common model across musculoskeletal conditions seems realistic, which points to an opportunity for reducing the complexity of implementation. We foresee this development will use big data sources and machine-learning methods to combine stepped and risk-stratified care and to integrate self-management support and patient-centred care to a greater extent in future models of care.
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Tagliaferri SD, Angelova M, Zhao X, Owen PJ, Miller CT, Wilkin T, Belavy DL. Artificial intelligence to improve back pain outcomes and lessons learnt from clinical classification approaches: three systematic reviews. NPJ Digit Med 2020; 3:93. [PMID: 32665978 PMCID: PMC7347608 DOI: 10.1038/s41746-020-0303-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 06/05/2020] [Indexed: 12/17/2022] Open
Abstract
Artificial intelligence and machine learning (AI/ML) could enhance the ability to detect patterns of clinical characteristics in low-back pain (LBP) and guide treatment. We conducted three systematic reviews to address the following aims: (a) review the status of AI/ML research in LBP, (b) compare its status to that of two established LBP classification systems (STarT Back, McKenzie). AI/ML in LBP is in its infancy: 45 of 48 studies assessed sample sizes <1000 people, 19 of 48 studies used ≤5 parameters in models, 13 of 48 studies applied multiple models and attained high accuracy, 25 of 48 studies assessed the binary classification of LBP versus no-LBP only. Beyond the 48 studies using AI/ML for LBP classification, no studies examined use of AI/ML in prognosis prediction of specific sub-groups, and AI/ML techniques are yet to be implemented in guiding LBP treatment. In contrast, the STarT Back tool has been assessed for internal consistency, test-retest reliability, validity, pain and disability prognosis, and influence on pain and disability treatment outcomes. McKenzie has been assessed for inter- and intra-tester reliability, prognosis, and impact on pain and disability outcomes relative to other treatments. For AI/ML methods to contribute to the refinement of LBP (sub-)classification and guide treatment allocation, large data sets containing known and exploratory clinical features should be examined. There is also a need to establish reliability, validity, and prognostic capacity of AI/ML techniques in LBP as well as its ability to inform treatment allocation for improved patient outcomes and/or reduced healthcare costs.
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Affiliation(s)
- Scott D. Tagliaferri
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC Australia
| | - Maia Angelova
- School of Information Technology, Deakin University, Geelong, VIC Australia
| | - Xiaohui Zhao
- Xi’an University of Architecture & Technology, Beilin, Xi’an China
| | - Patrick J. Owen
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC Australia
| | - Clint T. Miller
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC Australia
| | - Tim Wilkin
- School of Information Technology, Deakin University, Geelong, VIC Australia
| | - Daniel L. Belavy
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC Australia
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Lennon O, Ryan C, Helm M, Moore K, Sheridan A, Probst M, Cunningham C. Psychological Distress among Patients Attending Physiotherapy: A Survey-Based Investigation of Irish Physiotherapists' Current Practice and Opinions. Physiother Can 2020; 72:239-248. [PMID: 35110792 DOI: 10.3138/ptc-2019-0010] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: The primary purpose of this study was to investigate the current practice and opinions of members of the Irish Society of Chartered Physiotherapists (ISCP) with respect to the care of patients in psychological distress. Method: This was a cross-sectional, survey-based investigation of Irish physiotherapists. An electronic survey was sent by email to the ISCP membership. It consisted of closed- and open-ended questions, as well as opinion questions with Likert scale responses. Results: More than 80% of the respondents reported that they encountered patients with psychological distress at least once a week. A lack of education in the area of mental health emerged as a predominant theme. Reflecting on current practice, many discussed the importance of addressing underlying psychological issues before or in tandem with physical issues. Respondents who had engaged in further education in mental health, psychology, or both rated their confidence in recognizing the signs and symptoms of psychological distress higher (p < 0.001). Moreover, a greater proportion of these respondents routinely assessed for psychological distress in their clinical practice (p < 0.001). Conclusion: Physiotherapists regularly encounter patients whom they perceive to have high levels of psychological distress. Irish physiotherapists displayed positive attitudes toward patients' psychological well-being. However, additional education in mental health was a recognized need in the profession.
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Affiliation(s)
- Olive Lennon
- School of Public Health, Physiotherapy and Sports Science
| | - Cormac Ryan
- School of Public Health, Physiotherapy and Sports Science
| | - Maggie Helm
- School of Public Health, Physiotherapy and Sports Science
| | - Katrina Moore
- School of Public Health, Physiotherapy and Sports Science
| | - Ann Sheridan
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Michel Probst
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
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Langenmaier AM, Amelung VE, Karst M, Krauth C, Püschner F, Urbanski D, Schiessl C, Thoma R, Klasen B. Subgroups in chronic low back pain patients - a step toward cluster-based, tailored treatment in inpatient standard care: On the need for precise targeting of treatment for chronic low back pain. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2019; 17:Doc09. [PMID: 31728134 PMCID: PMC6838656 DOI: 10.3205/000275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 12/04/2018] [Indexed: 01/14/2023]
Abstract
Objective: The purpose of this study was to find applicable clusters for the development of different treatment pathways in an inpatient multimodal pain-therapy setting based on the multifaceted nature of CLBP. Methods: Based on data of questionnaires (Hospital Anxiety and Depression Scale (HADS), Marburg Questionnaire on Habitual Health Findings (MFHW), quality of life assessment using the Short-Form 12 (SF 12)), a retrospective two-step cluster analysis involving a sample of chronic low back pain (CLBP) patients (N=320) was calculated. Subsequently, the clusters were precisely described and compared on the basis of further data collected during the patients' standard care: pain characteristics, socio-demographic data and the general state of health, psychological variables, therapy intensity, and Diagnosis Related Groups (DRG) data. Results: We found a three-cluster solution: little psychological interference but marginal physical and mental quality of life (Cluster 1); poor well-being, low physical quality of life, and marginal mental quality of life (Cluster 2); and heavy mental strain and marginal physical quality of life (Cluster 3). Conclusions: Similar to previous studies, our results suggest that patients suffering from CLBP differ with regard to the magnitude of mental burden and the presence of physical impairment. These differences ascertain the need for precise targeting of treatment for CLBP. Inpatient pain centers therefore should offer different multimodal therapy pathways and integrate a meaningful triage, taking into account the multifaceted nature of CLBP based on sophisticated knowledge about forms, differences, and relationships among the biopsychosocial components of CLBP.
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Affiliation(s)
| | - Volker Eric Amelung
- Institut für Epidemiologie, Sozialmedizin und Gesundheitssystemforschung, Medizinische Hochschule Hannover, Germany
| | - Matthias Karst
- Institut für Anästhesie und Intensivmedizin, Medizinische Hochschule Hannover, Germany
| | - Christian Krauth
- Institut für Epidemiologie, Sozialmedizin und Gesundheitssystemforschung, Medizinische Hochschule Hannover, Germany
| | - Franziska Püschner
- inav - Privates Institut für angewandte Versorgungsforschung, Berlin, Germany
| | - Dominika Urbanski
- inav - Privates Institut für angewandte Versorgungsforschung, Berlin, Germany
| | - Christine Schiessl
- Algesiologikum - Zentren für Schmerzmedizin, Tagesklinik für Schmerzmedizin, Munich, Germany
| | - Reinhard Thoma
- Algesiologikum - Zentren für Schmerzmedizin, Algesiologikum MVZ Munich, Germany
| | - Bernhard Klasen
- Algesiologikum - Zentren für Schmerzmedizin, Algesiologikum MVZ Fürth, Germany
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18
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Hashimoto S, Hirokado M, Takasaki H. The most common classification in the mechanical diagnosis and therapy for patients with a primary complaint of non-acute knee pain was Spinal Derangement: a retrospective chart review. J Man Manip Ther 2018; 27:33-42. [PMID: 30692841 DOI: 10.1080/10669817.2018.1511316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Objectives: To preliminarily investigate in patients with a primary complaint of non-acute knee pain for ≥ 1 month: 1) the proportion of patients with non-acute knee pain classified by Mechanical Diagnosis and Therapy (MDT) as Spinal Derangements, 2) the number of sessions taken to identify the concluding classification, and 3) the ability of MDT classifications, demographics, and symptomatic baselines to predict pain reduction at 1-month follow-up.Methods: This study reviewed data from outpatients managed with MDT. For modeling knee pain reduction at the 1-month follow-up, 3 MDT provisional or concluding classifications (Spinal Derangement, Knee Derangement, and Non-Derangement) and the following variables were included: 1) gender, 2) symptom duration, 3) presence of low back pain (LBP), 4) the Japanese Knee Osteoarthritis Measure, 5) average pain intensity at the initial session using a 0-10 numerical rating scale, and 6) the Kellgren-Lawrence grade.Results: Data from 101 patients were extracted. The percentage of patients with the concluding classification of Spinal Derangement was 44.6%. This was greater in those patient's reporting concomitant LBP (p = .002) and without radiographic findings of knee osteoarthritis (p < .001). A concluding classification was determined by the fourth session in 80% of patients. Multiple regression modeling demonstrated that only the concluding classification significantly predicted the knee pain reduction at the 1-month follow-up.Discussion: These findings suggest the importance of careful screening assessments of the lumbar spine and the importance of detecting Derangements throughout the follow-up sessions for patients with a primary complaint of knee pain.
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Affiliation(s)
| | | | - Hiroshi Takasaki
- Department of Physical Therapy, Saitama Prefectural University, Saitama, Japan
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19
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Effect of Low Back Pain Risk-Stratification Strategy on Patient Outcomes and Care Processes: the MATCH Randomized Trial in Primary Care. J Gen Intern Med 2018; 33:1324-1336. [PMID: 29790073 PMCID: PMC6082187 DOI: 10.1007/s11606-018-4468-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 01/03/2018] [Accepted: 04/11/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND The STarT Back strategy for categorizing and treating patients with low back pain (LBP) improved patients' function while reducing costs in England. OBJECTIVE This trial evaluated the effect of implementing an adaptation of this approach in a US setting. DESIGN The Matching Appropriate Treatments to Consumer Healthcare needs (MATCH) trial was a pragmatic cluster randomized trial with a pre-intervention baseline period. Six primary care clinics were pair randomized, three to training in the STarT Back strategy and three to serve as controls. PARTICIPANTS Adults receiving primary care for non-specific LBP were invited to provide data 2 weeks after their primary care visit and follow-up data 2 and 6 months (primary endpoint) later. INTERVENTIONS The STarT Back risk-stratification strategy matches treatments for LBP to physical and psychosocial obstacles to recovery using patient-reported data (the STarT Back Tool) to categorize patients' risk of persistent disabling pain. Primary care clinicians in the intervention clinics attended six didactic sessions to improve their understanding LBP management and received in-person training in the use of the tool that had been incorporated into the electronic health record (EHR). Physical therapists received 5 days of intensive training. Control clinics received no training. MAIN MEASURES Primary outcomes were back-related physical function and pain severity. Intervention effects were estimated by comparing mean changes in patient outcomes after 2 and 6 months between intervention and control clinics. Differences in change scores by trial arm and time period were estimated using linear mixed effect models. Secondary outcomes included healthcare utilization. KEY RESULTS Although clinicians used the tool for about half of their patients, they did not change the treatments they recommended. The intervention had no significant effect on patient outcomes or healthcare use. CONCLUSIONS A resource-intensive intervention to support stratified care for LBP in a US healthcare setting had no effect on patient outcomes or healthcare use. TRIAL REGISTRATION National Clinical Trial Number NCT02286141.
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Suri P, Delaney K, Rundell SD, Cherkin DC. Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting. Arch Phys Med Rehabil 2018; 99:1533-1539.e2. [PMID: 29625095 DOI: 10.1016/j.apmr.2018.02.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/25/2018] [Accepted: 02/21/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To examine the predictive validity of the Subgrouping for Targeted Treatment (STarT Back) tool for classifying people with back pain into categories of low, medium, and high risk of persistent disabling back pain in U.S. primary care. DESIGN Secondary analysis of data from participants receiving usual care in a randomized clinical trial. SETTING Primary care clinics. PARTICIPANTS Adults (N = 1109) ≥18 years of age with back pain. Those with specific causes of back pain (pregnancy, disc herniation, vertebral fracture, spinal stenosis) and work-related injuries were not included. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The original 9-item version of the STarT Back tool, administered at baseline, stratified patients by their risk (low, medium, high) of persistent disabling back pain (STarT Back risk group). Persistent disabling back pain was defined as Roland-Morris Disability Questionnaire scores of ≥7 at 6-month follow-up. RESULTS The STarT Back risk group was a significant predictor of persistent disabling back pain (P<.0001) at 6-month follow-up. The proportion of individuals with persistent disabling back pain at follow-up was 22% (95% confidence interval [CI] 18-25) in the low-risk group, 62% (95% CI 57-67) in the medium-risk group, and 80% (95% CI 75-85) in the high-risk group. The relative risk of persistent disabling back pain was 2.9 (95% CI 2.4-3.5) in the medium-risk group compared to the low-risk group, and 3.7 (95% CI 3.1-4.4) in the high-risk group. CONCLUSIONS The STarT Back risk groups successfully separated people with back pain into distinct categories of risk for persistent disabling back pain at 6-month follow-up in U.S. primary care. These results were very similar to those in the original STarT Back validation study. This validation study is a necessary first step toward identifying whether the entire STarT Back approach, including matched/targeted treatment, can be effectively used for primary care in the United States.
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Affiliation(s)
- Pradeep Suri
- Seattle Epidemiologic Research and Information Center (ERIC), Department of Veterans Affairs Office of Research and Development, Seattle, Washington; Division of Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington.
| | - Kristin Delaney
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente, Seattle, Washington
| | - Sean D Rundell
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington
| | - Daniel C Cherkin
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente, Seattle, Washington
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Meyer C, Denis CM, Berquin AD. Secondary prevention of chronic musculoskeletal pain: A systematic review of clinical trials. Ann Phys Rehabil Med 2018; 61:323-338. [PMID: 29578102 DOI: 10.1016/j.rehab.2018.03.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 03/04/2018] [Accepted: 03/05/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Chronic musculoskeletal pain disorders are highly prevalent and have high personal and societal cost. Hence, early detection and care of patients at risk of developing chronic pain is important. Risk factors are well known and screening tools exist, but much less is known about the care of at-risk patients. The aim of this study was to investigate the effectiveness of secondary prevention strategies for musculoskeletal pain. METHODS We performed a systematic review of clinical trials in which treatments were adjusted to the risk of chronicity in adults with acute or subacute musculoskeletal pain. Clinical trials, systematic reviews and meta-analyses published after January 1, 2000 were searched in PubMed and PEDro databases and in the reference list of relevant papers. The risk of bias was assessed by the PEDro score. RESULTS We identified 4807 potentially eligible articles; 13, corresponding to 9 studies, met the inclusion criteria. Most studies investigated low back pain. The overall risk of bias was moderate, mainly because of the difficulty of blinding in physiotherapy studies. As compared with a "one-size-fits-all" treatment, stratified programmes showed significant improvements in several domains of the International Classification of Functioning, Disability and Health: body structures and functions (pain, mood), activities (functional capacity), participation (return to work, quality of life), as well as environmental factors (healthcare consumption). Effect sizes were moderate. Overall, simple educational messages seemed sufficient for low-risk patients. Medium- and high-risk patients benefited from a physical reactivation programme combined with education. In high-risk patients, an additional cognitive-behavioural intervention further improved the outcome. CONCLUSIONS A stratified approach seems effective in reducing long-term disability in patients with musculoskeletal pain. However, more research is necessary to confirm these results.
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Affiliation(s)
- Caroline Meyer
- Cliniques universitaires UCL Saint-Luc, department of Physical and Rehabilitation Medicine, avenue Hippocrate 10/1650, B-1200 Brussels, Belgium
| | - Camille M Denis
- Cliniques universitaires UCL Saint-Luc, department of Physical and Rehabilitation Medicine, avenue Hippocrate 10/1650, B-1200 Brussels, Belgium
| | - Anne D Berquin
- Cliniques universitaires UCL Saint-Luc, department of Physical and Rehabilitation Medicine, avenue Hippocrate 10/1650, B-1200 Brussels, Belgium.
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Takasaki H, Gabel CP. Cross-cultural adaptation of the 12-item Örebro musculoskeletal screening questionnaire to Japanese (ÖMSQ-12-J), reliability and clinicians' impressions for practicality. J Phys Ther Sci 2017; 29:1409-1415. [PMID: 28878473 PMCID: PMC5574346 DOI: 10.1589/jpts.29.1409] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 05/25/2017] [Indexed: 12/28/2022] Open
Abstract
[Purpose] To translate and culturally adapt the Örebro Musculoskeletal Screening
Questionnaire (ÖMSQ-12) into Japanese (ÖMSQ-12-J), and to preliminarily investigate
practicality from the clinicians’ perspectives, and determine inter-session reliability.
[Subjects and Methods] This study included four phases: cross-cultural adaptation (Phases
1–2); survey among 14 clinicians (two medical doctors and 12 physiotherapists) about the
practicality of using the questionnaire in six perspectives (speed of
evaluation/treatment; capacity to detect patients with yellow flags; attitude towards
management with bio-psycho-social perspectives; quality of evaluation/treatment;
considerations of communications with patients at history-taking, physical assessments and
interventions; and general clinical usefulness) based on their experiences with patients
(Phase 3); and investigation of inter-session reliability among 50 patients with
musculoskeletal disorders (Phase 4). [Results] The ÖMSQ-12-J was developed in Phases 1–2
using the recommended international guidelines for cultural adaptation and translation. In
Phase 3, most responses were in the 3-positive options (35.7–78.6%). In Phase 4, the
Intraclass Correlation Coefficient for each item ranged from 0.71–0.99 and 0.92 for the
total score. [Conclusion] This study developed the ÖMSQ-12-J, which has preliminary
evidence of good practicality and moderate-strong inter-session reliability. Further
investigation is required to determine the predictive and prognostic capacity within a
problematic musculoskeletal Japanese population.
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Affiliation(s)
- Hiroshi Takasaki
- Division of Physical Therapy, Saitama Prefectural University, Japan
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Bier JD, Sandee-Geurts JJW, Ostelo RWJG, Koes BW, Verhagen AP. Can Primary Care for Back and/or Neck Pain in the Netherlands Benefit From Stratification for Risk Groups According to the STarT Back Tool Classification? Arch Phys Med Rehabil 2017; 99:65-71. [PMID: 28709881 DOI: 10.1016/j.apmr.2017.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 05/31/2017] [Accepted: 06/05/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate whether current Dutch primary care clinicians offer tailored treatment to patients with low back pain (LBP) or neck pain (NP) according to their risk stratification, based on the Keele STarT (Subgroup Targeted Treatment) Back-Screening Tool (SBT). DESIGN Prospective cohort study with 3-month follow-up. SETTING Primary care. PARTICIPANTS General practitioners (GPs) and physiotherapists included patients (N=284) with nonspecific LBP, NP, or both. INTERVENTIONS Patients completed a baseline questionnaire, including the Dutch SBT, for either LBP or NP. A follow-up measurement was conducted after 3 months to determine recovery (using Global Perceived Effect Scale), pain (using Numeric Pain Rating Scale), and function (using Roland Disability Questionnaire or Neck Disability Index). A questionnaire was sent to the GPs and physiotherapists to evaluate the provided treatment. MAIN OUTCOME MEASURES Prevalence of patients' risk profile and clinicians' applied care, and the percentage of patients with persisting disability at follow-up. A distinction was made between patients receiving the recommended treatment and those receiving the nonrecommended treatment. RESULTS In total, 12 GPs and 33 physiotherapists included patients. After 3 months, we analyzed 184 patients with LBP and 100 patients with NP. In the LBP group, 52.2% of the patients were at low risk for persisting disability, 38.0% were at medium risk, and 9.8% were at high risk. Overall, 24.5% of the patients with LBP received a low-risk treatment approach, 73.5% a medium-risk, and 2.0% a high-risk treatment approach. The specific agreement between the risk profile and the received treatment for patients with LBP was poor for the low-risk and high-risk patients (21.1% and 10.0%, respectively), and fair for medium-risk patients (51.4%). In the NP group, 58.0% of the patients were at low risk for persisting disability, 37.0% were at medium risk, and 5.0% were at high risk. Only 6.1% of the patients with NP received the low-risk treatment approach. The medium-risk treatment approach was offered the most (90.8%), and the high-risk approach was applied in only 3.1% of the patients. The specific agreement between the risk profile and received treatment for patients with NP was poor for low-risk and medium-risk patients (6.3% and 48.0%, respectively); agreement for high-risk patients could not be calculated. CONCLUSIONS Current Dutch primary care for patients with nonspecific LBP, NP, or both does not correspond to the recommended stratified-care approach based on the SBT, as most patients receive medium-risk treatment. Most low-risk patients are overtreated, and most high-risk patients are undertreated. Although the stratified-care approach has not yet been validated in Dutch primary care, these results indicate there may be substantial room for improvement.
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Affiliation(s)
- Jasper D Bier
- Department of General Practice, Erasmus MC, Rotterdam, The Netherlands; FS Fysio, Capelle aan den IJssel, The Netherlands.
| | - Janneke J W Sandee-Geurts
- Faculty of Human Movement Sciences, VU, Amsterdam, The Netherlands; Fysiotherapie Kapellaan/Ouwerkerk, Vught, The Netherlands
| | - Raymond W J G Ostelo
- Department of Epidemiology and Biostatistics, VU University Amsterdam and the EMGO Institute for Health and Care Research, Amsterdam, The Netherlands; Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Bart W Koes
- Department of General Practice, Erasmus MC, Rotterdam, The Netherlands
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Evaluation of a risk-stratification strategy to improve primary care for low back pain: the MATCH cluster randomized trial protocol. BMC Musculoskelet Disord 2016; 17:361. [PMID: 27553626 PMCID: PMC4995645 DOI: 10.1186/s12891-016-1219-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 08/13/2016] [Indexed: 11/10/2022] Open
Abstract
Background Despite numerous options for treating back pain and the increasing healthcare resources devoted to this problem, the prevalence and impact of back pain-related disability has not improved. It is now recognized that psychosocial factors, as well as physical factors, are important predictors of poor outcomes for back pain. A promising new approach that matches treatments to the physical and psychosocial obstacles to recovery, the STarT Back risk stratification approach, improved patients’ physical function while reducing costs of care in the United Kingdom (UK). This trial evaluates implementation of this strategy in a United States (US) healthcare setting. Methods Six large primary care clinics in an integrated healthcare system in Washington State were block-randomized, three to receive an intensive quality improvement intervention for back pain and three to serve as controls for secular trends. The intervention included 6 one-hour training sessions for physicians, 5 days of training for physical therapists, individualized and group coaching of clinicians, and integration of the STarT Back tool into the electronic health record. This prognostic tool uses 9 questions to categorize patients at low, medium or high risk of persistent disabling pain with recommendations about evidence-based treatment options appropriate for each subgroup. Patients at least 18 years of age, receiving primary care for non-specific low back pain, were invited to provide data 1–3 weeks after their primary care visit and follow-up data 2 months and 6 months (primary endpoint) later. The primary outcomes are back-related physical function and pain severity. Using an intention to treat approach, intervention effects on patient outcomes will be estimated by comparing mean changes at the 2 and 6 month follow-up between the pre- and post-implementation periods. The inclusion of control clinics permits adjustment for secular trends. Differences in change scores by intervention group and time period will be estimated using linear mixed models with random effects. Secondary outcomes include healthcare utilization and adherence to clinical guidelines. Discussion This trial will provide the first randomized trial evidence of the clinical effectiveness of implementing risk stratification with matched treatment options for low back pain in a United States health care delivery system. Trial registration NCT02286141. Registered November 5, 2014. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1219-0) contains supplementary material, which is available to authorized users.
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